Sustainable Development Goals and Universal Health Coverage

SUSTAINABLE DEVELOPMENT GOALS
AND UNIVERSAL HEALTH COVERAGE

REGIONAL MONITORING FRAMEWORK
APPLICATIONS, ANALYSIS AND TECHNICAL INFORMATION
SUSTAINABLE DEVELOPMENT GOALS
AND UNIVERSAL HEALTH COVERAGE
REGIONAL MONITORING FRAMEWORK
APPLICATIONS, ANALYSIS AND TECHNICAL INFORMATION
© World Health Organization 2017
ISBN 978 92 9061 837 9
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CONTENTS
FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
ABBREVIATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
EXECUTIVE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
1. INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
STRUCTURE OF THE REPORT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. BACKGROUND. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
MDGS AND SDGS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3. THE SDG AND UHC REGIONAL MONITORING FRAMEWORK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.1 METHODS AND FRAMEWORK DEVELOPMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Indicator selection process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3.2 MONITORING DOMAINS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
3.3 MONITORING INDICATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4. COUNTRY APPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
4.1 HOW CAN COUNTRIES ADAPT THE SDG AND UHC REGIONAL MONITORING
FRAMEWORK TO THEIR OWN CONTEXT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
From data to policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Methods and analysis to support SDG and UHC monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
4.2 HOW CAN COUNTRIES USE LOGIC MODELS TO SUPPORT SDG AND UHC MONITORING? . . . . . . . 15
4.3 HOW CAN COUNTRIES CONDUCT EQUITY ANALYSIS AND MONITORING?. . . . . . . . . . . . . . . . . . . . . . 19
Gender analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Human rights-based analysis (or HRBA analysis). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
A focus on the social determinants of health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
4.4 HOW CAN COUNTRIES USE MONITORING DATA EFFECTIVELY IN POLICY-
AND DECISION-MAKING?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.5 WHAT MISTAKES SHOULD COUNTRIES AVOID WHEN MONITORING SDG AND UHC?. . . . . . . . . . . . 24
5. INDICATORS, DATA AND DATA SOURCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
5.1 SOURCES OF HEALTH INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Population-based data sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Institution-based data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
5.2 METADATA AND TRACER INDICATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Metadata. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Tracer Indicators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5.3 DATA AVAILABILITY AND EXISTING METHODOLOGIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
iii
6. MOVING FORWARD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
6.1 CHALLENGES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
6.2 SHORT-TERM OPPORTUNITIES AND SOLUTIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Strengthening HIS and health information capacities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Subnational geographic analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Electronic health records and data linkages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Development of new indicators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
6.3 OPPORTUNITIES IN THE MEDIUM AND LONG TERM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
APPENDIX 1. MONITORING FRAMEWORK FOR SDGS AND UHC IN THE WESTERN PACIFIC. . . . . . . . . . . 48
APPENDIX 2. WHO WESTERN PACIFIC REGION SDG AND UHC INDICATOR LIST . . . . . . . . . . . . . . . . . . . . . 49
Table A. SDG 3 Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Table B. Other health-related SDG Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Table C. Additional Indicators to monitor UHC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
APPENDIX 3. WHO WESTERN PACIFIC REGION MAPPING OF SDG AND UHC INDICATORS . . . . . . . . . . . 52
Table A. Health indicators in SDG 3 mapped to the SDG and UHC
Regional Monitoring Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Table B. Health indicators in other SDG mapped to the SDG and UHC
Table C. Additional indicators to monitor UHC mapped to the SDG and UHC
APPENDIX 4. REFERENCE LIST: 88 SDG AND UHC HEALTH INDICATORS LISTED ACCORDING
TO THE HEALTH SYSTEM RESULTS CHAIN (LOGIC MODEL). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
APPENDIX 5. EXAMPLES OF METADATA FOR 16 TRACER INDICATORS
(UHC SERVICE COVERAGE INDEX). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Reproductive, maternal, newborn and child health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Communicable diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Noncommunicable diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Service capacity and access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
APPENDIX 6. ADDITIONAL FOCUS AREAS FOR INDICATOR DEVELOPMENT
(MAPPED TO THE SDG AND UHC REGIONAL MONITORING FRAMEWORK) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
APPENDIX 7. LONG-TERM DATA OPPORTUNITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
iv
FOREWORD
I am pleased to release this technical report on the Sustainable Development Goals and Universal
Health Coverage Regional Monitoring Framework, which includes applications, analysis and technical
information. The report aims to support countries to guide, monitor and review progress towards
the health and health-related Sustainable Development Goal (SDG) targets and the achievement of
universal health coverage (UHC).
This report has three objectives. The first is to present and describe the SDG and UHC Regional
Monitoring Framework for the Western Pacific, including the Region’s core reference list of 88
indicators. This objective will enable Member States to adopt the globally agreed definitions for
standardized collection and analysis of data for both within- and cross-country comparison. The
second objective is to describe the adaptation of the Regional Monitoring Framework to a country’s
context and to support policy- and decision-making. The final objective is to provide technical
information on indicator development and analysis, and current and future monitoring activities.
The SDG and UHC Regional Monitoring Framework provides the basis to identify priority areas and
needs and to select monitoring indicators. Each country will need to build a monitoring framework
that meets its own priorities for policy- and decision-making. This will allow policy-makers to assess
where they are now and set a trajectory for where they want to go. The country’s framework will
help to show if efforts are focused in the right areas and whether they are making a difference. The
monitoring will also help foster dialogue on progress and encourage knowledge-sharing within
countries and also between countries in the Region.
This report is a technical resource for Member States. It aims to present the critical aspects of
monitoring in a user-friendly manner, to provide an appreciation of the complexities of the process,
and to share practical knowledge and techniques for systematic monitoring of the SDGs and UHC.
We hope countries will use this report as a guide to support monitoring efforts and activities,
and the formulation of evidence-informed policies, programmes and practices for health system
development.
Shin Young-soo, MD, Ph.D.

WHO Regional Director for the Western Pacific
v
ACKNOWLEDGEMENTS
This report was produced under the guidance of Dr Vivian Lin, Director of the Division of Health
Systems, with the technical assistance of Dr Guillermo A. Sandoval, WHO Consultant and Assistant
Professor at the University of Toronto Institute of Health Policy, Management and Evaluation, and
of Ms Navreet Bhattal, WHO Consultant. The work also benefited from the contributions made by
Dr Stephen John Duckett from the Grattan Institute in Australia.
Valuable contributions, comments and feedback were provided by the Health Intelligence and
Innovation Unit at the WHO Regional Office for the Western Pacific, by technical officers from the
Regional Office and WHO country offices, and by representatives from Member States.
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ABBREVIATIONS
AMI acute myocardial infarction
CRVS civil registration and vital statistics
CSDH Commission on Social Determinants of Health
DHIS District Health Information Software
DHS Demographic Health Survey
DTP3 diphtheria, tetanus and pertussis (three doses)
EHRs electronic health records
GIS geographic information systems
HIS health information system
HRBA human rights-based analysis
IAEG-SDG United Nations Statistical Commission’s Inter-Agency and Expert Group
on SDG Indicators
ICD-10 International Statistical Classification of Diseases and Related Health
Problems, 10th Revision
IHR (2005) International Health Regulations (2005)
IT information technology
LHIs leading health indicators
MDGs Millennium Development Goals
MICS Multiple Indicator Cluster Survey
NCDs noncommunicable diseases
NHA national health accounts
NHID National Health Information Database
NHIS National Health Insurance Service
SDGs Sustainable Development Goals
UHC universal health coverage
WHO World Health Organization
vii
EXECUTIVE SUMMARY
Monitoring progress towards the Sustainable Development Goals (SDGs) and universal health
coverage (UHC) is a priority in the Western Pacific Region. It is a complex process that includes a
wide range of activities, from data collection and infrastructure to data transformation and analysis
to inform and drive policy change. This technical report seeks to present a user-friendly overview of
the critical aspects of this monitoring to guide Member States as they improve and use their own
monitoring frameworks to review and evaluate progress towards the SDGs and UHC.
The SDG and UHC Regional Monitoring Framework described in this technical report was endorsed
at the sixty-seventh session of the Regional Committee for the Western Pacific in October 2016 (see
Appendix 1). The Framework sets out the priority areas to guide action over the next 14 years, to 2030,
and provides the basis for indicator selection by each Member State. The Framework is made up of
four overarching monitoring domains, within which are 17 indicator domains, currently comprising
a total of 88 indicators. Of these, 27 indicators fall under SDG 3, which is the health-focused goal, 20
are from other SDGs and 41 are additional indicators to monitor progress towards UHC.
The use of monitoring and indicator domains is flexible. Each Member State can select those domains
that best suit their priorities and needs and use them to build their own monitoring frameworks
or models, or overlap them with existing frameworks or models. The process of deciding what to
measure will require clear directions from each country and supportive analysis where indicators
are linked to help guide decisions on cost-effective policies and interventions.
To measure and report progress towards the SDGs and UHC, and to ensure that policies and actions
are evidence-based, each country will need robust monitoring and review processes to make timely
and high-quality data available to planners and practitioners. This technical report addresses five
questions to guide SDG and UHC monitoring in the Western Pacific Region:
1. How can countries adapt the SDG and UHC Regional Monitoring Framework to their own context?
2. How can countries use logic models to support SDG and UHC monitoring?
3. How can countries conduct equity analysis and monitoring?
4. How can countries use monitoring data effectively in policy- and decision-making?
5. What mistakes should countries avoid when monitoring SDGs and UHC?
Question 1 summarizes the process or steps to build a monitoring framework that is integrated
with a country’s priorities and needs. Questions 2 and 3 describe models to respond to analytical
needs in policy- and decision-making. Question 4 deals with the communication of monitoring data
to different audiences, and Question 5 describes some common scenarios of risk to the effective
monitoring of SDGs and UHC.
Effective monitoring of SDG and UHC progress will require a strong national health information
system (HIS). A well-managed HIS supports decision-making, accountability and the coordination of
health investment from all stakeholders, including government and donors. Country leadership will
viii
be essential to building a strong HIS. Some key guiding components of a well-functioning national
HIS, for which best practices should be pursued, include:
yy governance
yy information use and transparency
yy infrastructure
yy human capital development
yy system and data interoperability.
These components can assist countries to shift focus and attention to more strategic areas by
providing a foundation for discussion and a framework for action. An example of a best practice
under governance would include an active national coordinating body (such as the National
Statistics Office) with strong oversight and control, working with multiple agencies and sectors,
and with strong human, technical and financial capacities to meet the country’s needs for data
collection, disaggregated data and analysis. Under good governance, the Ministry of Health would
provide continuous leadership and coordination and both broad and specific incentives for data-
sharing and use, and would lead coordinated government-led direct and indirect incentive-based
investments in basic information infrastructure and tools. The availability of reliable, good-quality
data and information will enable priority-setting and informed decision-making, and will promote
accountability of various stakeholders.
Effective monitoring of SDG and UHC progress will also require addressing some commonly identified
regional challenges, such as those involved with data collection and gaps, and those related to the
strengthening of health information systems and capacities. Specifically, these challenges include:
yy limited data availability

yy insufficient disaggregated data
yy poor data quality and reliability
yy silos/fragmented information systems
yy limited use of information standards and exchange mechanisms
yy poor information infrastructure and tools
yy limited capacity to generate knowledge for decision-making.
Meeting these challenges will require improvements in governance, commitment and leadership;
short- and long-term investment in health information infrastructure and human resources; and
innovative approaches to the use of existing data sources. The range of diversity of countries in the
Western Pacific Region – in terms of current monitoring-related readiness and activities – means
that countries will have different pathways, timelines and priorities for building up their monitoring
capability and processes.
ix
1. INTRODUCTION
The World Health Organization (WHO) Regional Office for the Western Pacific has prepared this
technical report to support Member States to guide, monitor and review their progress towards
the health-related Sustainable Development Goals (SDGs) and the achievement of universal health
coverage (UHC). The document describes the SDG and UHC Regional Monitoring Framework and
addresses a series of questions to guide Member States as they work to build and use their own
monitoring framework to inform policy- and decision-making.
The aim of monitoring SDGs and UHC by individual countries is to ensure that progress reflects
each country’s epidemiological and demographic profile, health system and level of economic
development, as well as the demands and needs of its population.1 These country-specific dimensions
are critical for deciding what should be monitored. For example, emerging economies may focus on
expanding essential services to remote areas. Countries with limited financial and human resources
may develop a monitoring framework that focuses on high-burden health issues and Millennium
Development Goals (MDGs) that have not yet been achieved. Developed economies, on the other
hand, may focus on modifying service delivery to improve coordination of care for the growing
older population, ensuring people-centred services, with more emphasis on health promotion and
prevention and removing inequities in service delivery.
At the regional level, measuring and analysing progress towards the SDGs and UHC will help
identify the challenges faced by the Region and their potential root causes, and provide evidence
to develop policies and programmes for equitable health improvement in the populations of all
Member States.
Structure of the report

This report consists of six chapters. Following the introduction in Chapter 1, Chapter 2 summarizes
the official global and regional work completed to date on SDGs and UHC, and the relationship
between the MDGs and the SDGs. Chapter 3 presents the SDG and UHC Regional Monitoring
Framework, with a description of the indicator selection process and the core reference list of 88
proposed indicators.2 Chapter 4 describes a guiding process that includes actions each country can
take to adapt the Regional Framework to its own policy priorities and decision-making.
Chapter 5 summarizes technical information on the collection, measurement, analysis and reporting
of data. Chapter 6 sets out the main challenges to be addressed for effective monitoring of SDG and
UHC progress, and outlines short- and long-term solutions and opportunities.
The appendices provide additional information, including the complete list of monitoring indicators
and their mapping to the monitoring framework, metadata for proposed tracer indicators for
coverage of the essential health services index, and additional details on the opportunities outlined
in Chapter 6.
1
Towards a monitoring framework with targets and indicators for the health goals of the post-2015 Sustainable Development Goals. Geneva:
World Health Organization; 2015 (http://www.who.int/healthinfo/indicators/hsi_indicators_sdg_targetindicators_draft.pdf; accessed 21
August 2017).
2
The core list will evolve and may be modified in the future.
1
2. BACKGROUND
In September 2015, the General Assembly of the United Nations (UN) adopted the 2030 Agenda
for Sustainable Development.3 The Agenda includes 17 SDGs, with 169 associated targets, which
are intended to ensure that all human beings can fulfil their potential in dignity and equality and
in a healthy environment. While SDG 3 aims to “ensure healthy lives and promote well-being for all
at all ages”, core health targets are also embedded in other SDGs. In May 2016, the World Health
Assembly reaffirmed the 2030 Agenda and urged Member States to scale up comprehensive action
at the national, regional and global levels to achieve the goals and targets of the 2030 Agenda for
Sustainable Development relating to health by 2030.4
In June 2016, a regional consultation on achieving the SDGs in the Western Pacific was held in Manila.
The consultation and follow-up work focused on the place of health in the SDGs and the monitoring
of the SDGs. A Regional Action Agenda on Achieving the Sustainable Development Goals in the Western
Pacific was endorsed at the sixty-seventh session of the Regional Committee for the Western Pacific
in October 2016.5 This Agenda provides guidance on actions to accelerate achievement of the SDGs,
building on the regional action framework Universal Health Coverage: Moving Towards Better Health
endorsed at the sixty-sixth session of the WHO Regional Committee for the Western Pacific in
October 2015.6
MDGs and SDGs

The MDGs, adopted at the United Nations Millennium Summit in 2000, guided global development
planning and action from 2000 to 2015, with remarkable progress achieved. Health was central to
the MDGs as the explicit focus of three of the eight goals and linked with, or influenced by, the other
five goals. Progress towards the MDGs was realized largely through programmatic approaches
targeting specific disease and health issues. Globally, the HIV, tuberculosis and malaria epidemics
were, to varying degrees, contained; and child and maternal mortality decreased, despite falling
short of the MDG targets.
However, this progress towards the MDGs did not benefit all groups in society equally, and many
programmes neglected to build on links between the different goals. Overall, the most progress was
made among the groups that were easiest to reach or whose situations were easiest to improve,
leaving behind many of the poorest and most disadvantaged. It became clear that for development
to benefit everyone, more integrated and inclusive strategies were needed. Thus, the SDGs
address a more complex agenda than did the MDGs, building on the interconnections of different
3
Resolution adopted by the General Assembly on 25 September 2015 (A/Res/70/1). New York: United Nations; 2015 (http://www.un.org/en/ga/
search/view_doc.asp?symbol=A/RES/70/1; accessed 21 August 2017).
4
Health in the 2030 Agenda for Sustainable Development. Geneva: World Health Organization; 2016 (http://apps.who.int/gb/ebwha/pdf_files/
WHA69/A69_R11-en.pdf; accessed 21 August 2017).
5
Regional action agenda on achieving the Sustainable Development Goals in the Western Pacific. Manila: WHO Regional Office for the Western
Pacific; 2016 (http://www.wpro.who.int/about/regional_committee/67/documents/wpr_rc67_8_sdgs.pdf; accessed 21 August 2017).
6
WHO Regional Committee for the Western Pacific Resolution WPR/RC66/6 on universal health coverage. Manila: WHO Regional Office for the
Western Pacific; 2015 (http://www.wpro.who.int/about/regional_committee/66/documents/wpr_rc66_06_uhc_7sep.pdf?ua=1; accessed 21
August 2017).
2
BACKGROUND
development challenges. The SDG Agenda has an explicit focus on equity and serving the hardest-
to-reach populations to ensure that “no one is left behind”, with UHC acting as a unifying platform.7
SDG 3 in particular builds on and extends the MDG health agenda. SDG 3 has nine targets or
subgoals. Three of these relate to the MDGs, three are concerned with noncommunicable disease
(NCD) and injury, and three are cross-cutting or systems-focused, including UHC. Thus, UHC is a
specific target within SDG 3, as well as the platform that links programmes and actions for health
and development. Four additional targets – referred to as means-of-implementation targets – have
also been identified (for example, strengthen implementation of the WHO Framework Convention
on Tobacco Control).8
Crucially, core health issues are also included in other goals beyond SDG 3. This means that the health
SDG is complementary to and a beneficiary of several other goals, including the implementation of
social protection schemes (SDG 1); food security and nutrition (SDG 2); gender equality and reducing
all forms of violence against women and girls (SDG 5); safe drinking water and adequate sanitation
and hygiene (SDG 6); making cities inclusive, safe, resilient and sustainable (SDG 11); and promoting
peaceful and inclusive societies and reducing all forms of violence and related deaths (SDG 16). SDGs
13, 14 and 15, which focus on ecosystems and environmental well-being, also indirectly complement
SDG 3.
The SDG Agenda emphasizes the linkages between the goals, the use of integrated, collaborative
and participatory approaches to sustainable development and “leaving no one behind”. This
emphasis is especially relevant in the Western Pacific Region, which has significant and growing
differences in health and well-being, both among and within countries and areas. Thus, the SDG
Agenda has greater focus on identifying and addressing disparities across population groups – not
only as a matter of fairness and social justice but also as a critical factor in sustainability.
7
Regional action agenda on achieving the Sustainable Development Goals in the Western Pacific. Manila: WHO Regional Office for the Western
Pacific; 2016 (http://www.wpro.who.int/about/regional_committee/67/documents/wpr_rc67_8_sdgs.pdf; accessed 21 August 2017).
8
Towards a monitoring framework with targets and indicators for the health goals of the post-2015 Sustainable Development Goals. Geneva:
World Health Organization; 2015 (http://www.who.int/healthinfo/indicators/hsi_indicators_sdg_targetindicators_draft.pdf; accessed 21
August 2017).
3
3. THE SDG AND UHC REGIONAL MONITORING
FRAMEWORK
This chapter presents the SDG and UHC Regional Monitoring Framework. It describes the indicator
selection process and lists the 88 core reference indicators proposed to date. The Framework sets
out the priority areas to guide action over the next 14 years, to 2030. Each country is expected to
use these indicators as a reference to undertake its own regular monitoring and review, guided by
its own national health policies, priorities and strategies, and making best use of its monitoring
capacity.
3.1 Methods and framework development

The SDG and UHC Regional Monitoring Framework builds on extensive work conducted over the last
decade at global, regional and national levels. This work includes the UHC Action Framework for the
Western Pacific Region,9 the WHO–World Bank global framework for monitoring UHC,10 the WHO
frameworks for health systems performance11 and for the social determinants of health,12 and the
framework for health care quality of the Organisation for Economic Co-operation and Development
(OECD).13
The Regional Monitoring Framework is presented in Figure 1. It is organized into four common,
standardized monitoring domains (for example, health system resources and capacity) and 17
indicator domains (for example, quality and safety). Some countries, including Canada and Australia,
have made extensive use of this type of information framework to monitor performance and the
achievement of the strategic objectives of their health systems.14
The advantage of this type of framework is that each country can identify the monitoring and
indicator domains that are relevant to its own national context, and can use them to build up its
own monitoring framework or models. The following chapter (Chapter 4) discusses how to adapt
the SDG and UHC Regional Monitoring Framework to a country’s context to support policy- and
decision-making. The Framework is expected to evolve further over time.
9
Universal health coverage: moving towards better health. Action framework for the Western Pacific Region. Manila: WHO Regional Office for
the Western Pacific; 2016 (http://iris.wpro.who.int/bitstream/handle/10665.1/13371/9789290617563_eng.pdf?sequence=1; accessed 21 August
2017).
10
Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets. Geneva: WHO and
World Bank; 2014 (http://apps.who.int/iris/bitstream/10665/112824/1/WHO_HIS_HIA_14.1_eng.pdf?ua=1; accessed 21 August 2017); Boerma T,
AbouZahr C, Evans D, Evans T. Monitoring intervention coverage in the context of universal health coverage. PLoS Med. 2014:11(9):e1001728.
11
Monitoring, evaluation and review of national health strategies: a country-led platform for information and accountability. Geneva: World
Health Organization; 2011 (http://www.who.int/healthinfo/country_monitoring_evaluation/1085_IER_131011_web.pdf; accessed 21 August
2017).
12
Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper
2. Geneva: World Health Organization; 2010 (http://apps.who.int/iris/bitstream/10665/44489/1/9789241500852_eng.pdf?ua=1; accessed 21
August 2017).
13
Kelley E, Hurst J. Health care quality indicators project: conceptual framework paper. OECD Health Working Papers No. 23. Paris: Organisation
for Economic Co-operation and Development; 2006 (http://www.oecd.org/els/health-systems/36262363.pdf; accessed 21 August 2017).
14
Hurst J, Jee-Hughes M. Performance measurement and performance management in OECD health systems. OECD Labour Market and Social
Policy Occasional Papers, No. 47. Paris: Organisation for Economic Co-operation and Development; 2001.
4
THE SDG AND UHC REGIONAL MONITORING FRAMEWORK
Indicator selection process
The indicators used in this Framework were identified from the SDG indicators, from existing global
collections of health indicators (including those used in the Pacific islands) and from various other
programmes. Existing data were leveraged to the extent possible so as to minimize the need for
extra reporting from Member States. The selection of indicators aims to provide adequate coverage
of all population groups and to show progress on UHC and the potential drivers of progress by
including inputs, structures and processes, as well as outcome indicators.
Figure 1. SDG and UHC Regional Monitoring Framework
HEALTH IMPACT THROUGH THE LIFE COURSE How healthy are people in the Western Pacific?
Indicator Domain INDIVIDUAL HEALTH
1. Mortality
2. Morbidity
MULTIPLE POPULATION GROUPS (EQUITY-FOCUSED MONITORING)

3. Life expectancy and well- POPULATION HEALTH
being
DETERMINANTS OF HEALTH Are these factors contributing to good health?

Indicator Domain
1. Physical environment factors
2. Individual characteristics and behaviours
3. Socioeconomic factors
4. Social environment factors
UNIVERSAL HEALTH COVERAGE Are all people accessing needed services

without suffering financial hardship?
Indicator Domain
1. Financial protection
2. Health service coverage
3. Accessibility and use
HEALTH SYSTEM RESOURCES AND CAPACITY Does the system deliver value for money and is
it sustainable?
Indicator Domain 4. Resources and infrastructure
1. Effectiveness 5. Availability and readiness
2. Quality and safety 6. Health financing
3. Responsiveness and people- 7. Efficiency and sustainability
centredness
Source: Adapted from the Framework agreed to at the sixty-seventh session of the Regional Committee of the Western Pacific in October 2016.
5
SDG AND UHC REGIONAL MONITORING FRAMEWORK
The selection process began with a review of the 230 indicators identified for the United Nations
Statistical Commission’s global indicator framework for monitoring SDGs.15 Those deemed to be
health or health-related were compiled, including the 27 health indicators from SDG 3 and 20 health-
related indicators from other SDGs.
Additional indicators were selected after review of the WHO Global Reference List of 100 Core Health
Indicators, Universal Health Coverage: Moving Towards Better Health framework adopted by Member
States in the Western Pacific Region in October 2015, and the Healthy Islands Monitoring Framework
endorsed by the Pacific heads of health in April 2016.16 During this review, indicators that were
duplicated or had been replaced by improved ones were removed.
This was followed by technical consultations and a prioritization exercise within the WHO Regional
Office for the Western Pacific. Informed by reports of similar exercises,17 the following criteria were
used to determine a list of “fit for purpose” indicators:
1. Focus on common health issues and indicators across the Western Pacific Region to allow within-
country and cross-country comparisons, mutual learning and sharing of experience.
2. Align the regional-level indicators with existing global collections where possible to encourage
information/data exchange between Member States in the Region.
3. Ensure that, in addition to tracking progress in SDGs and UHC, the indicators can be used to
review progress and to support policy and programme development at multiple levels (national,
subnational, local) and for different population groups.
4. Ensure where possible that information to track progress towards SDGs and UHC is disaggregated
by sex, age, socioeconomic status, education, ethnicity and place of residence.
5. Ensure the indicators are theoretically sound, commonly understood and technically accurate.
6. Ensure that the indicators reflect a balance in selection of targets, not overemphasizing one
health condition, but capturing characteristics that reflect the health profile of country
populations.
Using this indicator selection process, the SDG and UHC Regional Monitoring Framework currently
includes a total of 88 indicators in three groups. Of these, 27 indicators fall under SDG 3 (health),
20 are from other SDGs, and 41 are additional indicators of progress towards UHC. Appendix 2
summarizes the complete list of 88 indicators in these three categories.
3.2 Monitoring domains

The SDG and UHC Regional Monitoring Framework sets out priority areas to guide action over the next
14 years. These areas are grouped into four monitoring domains made up of 17 indicator domains.
The monitoring domains are broad conceptual categories that define SDG and UHC progress. They
allow the grouping of the indicator domains in ways that are meaningful and conceptually related,
15
United Nations Statistical Commission. Report of the Inter-Agency and Expert Group of Sustainable Development Goal Indicators. New York:
United Nations Economic and Social Council; 2016 (http://unstats.un.org/unsd/statcom/47th-session/documents/2016-2-SDGs-Rev1-E.pdf;
accessed 21 August 2017).
16
Global reference list of 100 core health indicators, 2015. Geneva: World Health Organization; 2015 (http://www.who.int/healthinfo/indicators/2015/
en/; accessed 21 August 2017); Universal health coverage: moving towards better health. Action framework for the Western Pacific Region. Manila:
WHO Regional Office for theWestern Pacific; 2016 (http://iris.wpro.who.int/bitstream/handle/10665.1/13371/9789290617563_eng.pdf?sequence=1;
accessed 21 August 2017); Soakai S, Park K. Healthy island monitoring framework. Manila: WHO Regional Office for the Western Pacific; n.d.
(http://nebula.wsimg.com/e7c7ae233b713a901255052f7895d57e?AccessKeyId=3BF845C13E3CC727DFDB&disposition=0&alloworigin=1;
17
Criteria for leading health indicators. Washington, DC: Institute of Medicine; 1998 (https://www.ncbi.nlm.nih.gov/books/NBK230723/; accessed
21 August 2017).
6
THE SDG AND UHC REGIONAL MONITORING FRAMEWORK
so that when indicators are reported, they all measure an important dimension of the SDGs and
UHC. For example, mortality, morbidity and life expectancy and well-being are all related indicator
domains to measure how healthy people are in the Western Pacific Region.
The use of these monitoring and indicator domains is flexible. Each Member State can select the
domains that best suit their priorities and use them to build their own monitoring frameworks or
models, or overlap them with existing frameworks or models. Figure 1 outlines the main components
of the Framework, which is organized under the following four monitoring domains:
1. Health impact through the life course

2. Determinants of health
3. Universal health coverage
4. Health system resources and capacity.
The first monitoring domain – health impact through the life course – captures the level of health
of people in the Western Pacific Region at different stages of life, from the prenatal period, through
adolescence and youth, to the adult years and into older age. The focus of this domain is on health
status changes for both individuals and populations, measured through mortality, morbidity, and
life expectancy and well-being. As an outcome-oriented domain, this monitoring domain is less
actionable, but it reflects the combined progress made in the other three domains – determinants
of health, UHC, and health system resources and capacity.
The domain determinants of health contains the personal, social, economic and environmental
factors that influence health status. These determinants often contribute to health inequity, which is
the unfair and avoidable difference in health status seen within and between populations. They are
classified into three groups: physical environment factors; individual characteristics and behaviours;
and social environment factors.
Some fundamental determinants of health are not included in the present Regional Framework, such
as poverty, education and employment. Individual countries may consider including these in their
country-specific frameworks. Examples of these indicators include the proportion of the population
living in poverty, and the proportion of youth and adults who have achieved literacy and numeracy.
The indicator domain “socioeconomic factors” reflects the importance of these determinants and
the interlinkages between health and other SDGs, which also provide the basis for equity analysis.
The third monitoring domain, universal health coverage (UHC), is the vision that all people are
able to obtain quality health services without suffering financial hardship. UHC is the foundation for
SDG 3, while also contributing to other SDGs as a pathway to more equitable and sustainable health
outcomes and more resilient health systems. This monitoring domain incorporates three indicator
domains: financial protection; health service coverage; and accessibility and use.
As a platform for SDG 3, UHC has more actionable domains. For example, evidence showing
significant variation in skilled birth attendance between urban and rural populations may help
countries to adjust health policies and interventions on health worker density and distribution.
Similarly, data on impoverishing health expenditure by certain disadvantaged groups – persons
with disabilities, ethnic minorities, older persons, working poor – may provide the basis to develop
a policy or action plan for improved financial protection.
The fourth monitoring domain, health system resources and capacity, aims to assess and monitor
whether the system is delivering value for money and whether it is sustainable. This domain also
7
seeks to monitor quality of care for a range of patient care activities. It contains seven indicator
domains, with a substantial number of actionable indicators. For example, within the indicator
domain “resources and infrastructure”, birth registration capability is relevant to measuring progress
in several SDGs, as well as to support direct health actions, strategies and interventions.
Equity-focused monitoring is integral to each of the four domains, in line with the aim of the SDGs
to ensure that no one is left behind. Creation of an equity-oriented health sector requires first the
systematic identification of inequities, and then monitoring of any change in these inequities over
time.18
The monitoring process and activities outlined in the Framework should be country-led and country-
owned. Member States are expected to develop their monitoring mechanisms based on their own
SDG and UHC priorities, adjusting for the relative importance that the country attaches to each SDG
target. These country-focused priorities will be conditioned by factors outside the health system
that may influence the expected level of goal attainment, including a country’s income, education
levels and political factors.
3.3 Monitoring indicators

This section summarizes the core reference list of 88 indicators selected by the Region for monitoring
progress towards the SDGs and UHC over time. Progress in these indicators is essential to ensure
that the development goals are met across various population groups.
The use of these common indicators, with globally agreed definitions, allows comparison, both
within and across countries, of trends, successes, challenges and opportunities, including locality-,
equity- and gender-based analyses across population groups. Countries should use these indicators
as a reference for their own regular monitoring and review, guided by their national health policies,
priorities, strategies and capacity to implement monitoring activities.
The 88 indicators of the core reference list have been mapped to the monitoring and indicator
domains of the Framework, as outlined in Figure 1. Appendix 2 presents the complete list of indicators
and Appendix 3 shows the complete mapping of indicators.
The definitions of the indicators in the Framework provide a level of specificity to help countries
assess focus areas. For example, harmful use of alcohol is in the indicator domain “individual
characteristics and behaviours”, within the monitoring domain “determinants of health”. Setting goals
for this indicator, based on progress expected from the baseline value, provides a guide to develop
policies and interventions to modify this behaviour. Monitoring this indicator (that is, “harmful use
of alcohol”) will help measure progress towards SDG 3.5, which aims to improve prevention and
treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.
The complete framework in Appendix 3 provides the basis for indicator selection by each Member
State. The process of deciding what to measure will require clear directions from each country on
priorities and needs, and supportive analysis where indicators are linked, to help guide decisions
on cost-effective policies and interventions. The next chapter provides examples of analyses and
models to illustrate how countries can apply this framework within their own national monitoring
activities.
18
Handbook on health inequality monitoring: with a special focus on low- and middle-income countries. Geneva: World Health Organization;
2013 (http://apps.who.int/iris/bitstream/10665/85345/1/9789241548632_eng.pdf; accessed 21 August 2017).
8
4. COUNTRY APPLICATIONS
Based on the SDG and UHC Regional Monitoring Framework, Member States themselves need to
identify those targets and indicators of highest priority, taking into account the country realities,
characteristics, challenges and capacities. To measure and report on the SDGs and UHC, and to
ensure that policies and actions are informed by evidence, each country needs to have robust
monitoring and review processes, with timely and high-quality data and information available to
planners and practitioners.
This chapter offers a guide to Member States as they prepare to build or adapt their own monitoring
framework. The chapter addresses five guiding questions in five sections (Figure 2).
Figure 2. Guiding questions to support countries in SDG and UHC monitoring
3. How can countries

conduct equity analysis
2. How can countries and monitoring? 4. How can countries
use logic models to use monitoring data
support SDG and UHC effectively in policy- and
monitoring? decision-making?
1. How can countries adapt

SDG and UHC 5. What mistakes should
the SDG and UHC Regional
countries avoid when
Monitoring Framework to their Monitoring monitoring SDGs and UHC?
own context?
Question 1 summarizes a guiding process to build a monitoring framework that is integrated with a
country’s priorities and needs. This includes a wide range of activities, stages and aspects involved
in monitoring. Questions 2 and 3 describe models to respond to analytical needs in policy- and
decision-making. Question 4 discusses the importance of communicating monitoring data to
different audiences, and Question 5 describes some common scenarios that may limit the effective
monitoring of SDGs and UHC.
9
4.1 How can countries adapt the SDG and UHC Regional Monitoring
Framework to their own context?
Overview
To monitor progress towards SDGs and UHC, each country needs to have a monitoring framework
that responds to their own priorities and needs, and that supports policy- and decision-making. The
SDG and UHC Regional Monitoring Framework provides the basis to identify priority areas and needs,
and to select suitable monitoring indicators. The formulation of a country’s monitoring framework
should integrate with the policy development cycle. This is an organized process to define and target
focus areas for policy changes and interventions (Figure 3), and typically involves four main stages:
1. problem definition or redefinition

2. agenda setting
3. policy formulation
4. policy implementation and evaluation.
Figure 3. Opportunities to incorporate monitoring data into policy- and decision-making
Equity analysis and monitoring
1. Problem
1 2
SDG AND UHC definition
Country Policy 2. Agenda setting
Regional
INFORM Monitoring Development 3. Policy formulation
Monitoring
Framework Cycle 4. Policy
Framework
4 3 implementation
and evaluation
The country monitoring framework has the potential to inform every stage and level of policy- and
decision-making, and should evolve following new developments and directions arising from the
policy development process. For example, the evaluation of a policy or intervention may lead to
changes in policy and programme priorities. The country monitoring framework will need to be
adjusted to reflect these changes. Health policies within a country are typically at different stages
of development. This means countries may not necessarily have to go through the complete
policy development process, but rather find opportunities within already established processes to
incorporate the use of monitoring data to support policy- and decision-making.
As mentioned, equity analysis is an important element of policy- and decision-making. Equity analysis
involves the use of disaggregated data and other equity-oriented approaches to systematically
identify and monitor excluded and disadvantaged population groups. Equity analysis can be
especially valuable during the processes of problem definition and policy evaluation.
10
COUNTRY APPLICATIONS
From data to policy
Monitoring progress towards the SDGs and UHC is a complex and demanding process. It includes
a wide range of activities, including data collection, provision of information technology (IT)
infrastructure and then data processing and analysis to inform and drive policy improvement. The
aim of country-specific monitoring of SDGs and UHC is to be able to ensure that progress reflects
each country’s own epidemiological and demographic profile, health system, and level of economic
development, as well as the demands and needs of the population.
Figure 4 depicts the monitoring process as a data-to-policy continuum, where the ultimate goal
is to make progress towards the SDGs and UHC. The range of diversity of countries in the Western
Pacific Region in terms of current monitoring systems and activities means that countries will have
different pathways, timelines and priorities throughout this process. The data-to-policy continuum
recognizes both the role of other sectors in data linkages and engagement, and also the multiple
options and restrictions countries will face throughout the monitoring process.
Figure 4 highlights a two-part process. The first stage describes the key elements and actions that
are needed for a country to select indicators. Key supporting elements in this process include data
and IT infrastructure, a data governance and information plan, and a country-specific monitoring
framework. Key actions include data transformation, comparative analysis and indicator selection.
During this first stage, WHO can support countries with development and provision of metadata,
assessment of data and indicator maturity, data transformation processes, comparative data
analysis, and the development of a data and information plan, and a country-specific monitoring
framework. For example, WHO can support assessment of current data and indicator availability so
that an action plan can be developed to strengthen data governance and IT infrastructure.
The second part of the process presents a series of actions for which the use of the selected
indicators is the main focus. The main actions involve target-setting, policy and action, and progress
monitoring. During this second stage of monitoring, WHO can support countries in the use of logic
models and indicator sequencing to set targets and make policy changes, and by producing regular
regional reports to compare baseline and progress towards the SDGs and UHC across countries.
The data-to-policy continuum recognizes two types of indicators. The first type groups indicators
for which the cause and effect of related interventions are relatively clear. For example, child
immunization is important for overall children’s health and likely a significant predictor of under-5
mortality. Targeting child immunization as a priority action will probably generate little debate
about its effectiveness, target-setting and policy options to improve child immunization. The second
type groups indicators for which the cause and effect of related interventions are still debatable.
For example, in the case of harmful use of alcohol, there may be significant debate about what
interventions may be most effective to change this behaviour.
The selection of indicators should be based on each country’s priorities and needs so that progress
can be measured in relevant areas where policy changes and interventions are being considered.
When it comes to individual metrics, however, countries will have to use certain criteria to support
their decision-making process. In general, a good indicator should be relevant to what is to be
measured and should be clear, practical, doable and appropriate.19 Indicators need to contain
certain basic information and should pass tests of reliability, feasibility and utility in decision-
19
Indicator module section 3.5. Washington, DC: Search for Common Ground and UK Aid; n.d. DME for Peace [website] (http://dmeforpeace.org/
sites/default/files/3.9%20Indicators.pdf; accessed 21 August 2017).
11
Figure 4. Monitoring process (as a data-to-policy continuum)
SUSTAINABLE DEVELOPMENT GOALS (SDGs)

UNIVERSAL HEALTH COVERAGE (UHC)
Monitoring Framework
Progress Monitoring Baseline Report
• Common
syntax supply Action / Policy
-- Analysis,
visualization Help with
• Ideas sharing, sequencing,
priority Help with logic model,
PHIN,
setting
Target Setting sequencing
mutual
support,
exchange
• Capacity-
building, Indicators for which cause- Indicators for which cause-
knowledge and-effect is relatively clear and-effect is debatable
transfer
• Advice on
advisers Comparative data
Data Transformation Indicator Selection Comparative Data,

• Data analysis and • What metrics, methods
display • What to highlight Benchmarks
• Enhancing value add • How to disaggregate and Trend Data
• Analysis, linkages,
summary measures,
tracer indicators
• Transparency choices (to Data and Information Plan • Politics (private sectors, other
sectors, civil society)
whom) Country-Specific • Priority setting for new data
Monitoring Framework collections
CRVS, Infections, RMNCH • Avoiding duplication
Maturity assessment Hospital, NCDs • Working on rationalizing
external demands (partners,
donors, WHO requests)
Metadata (global, local)

Data Governance
Ideas sharing Audit, data flow to enhance meaning
e.g. automation
Data + IT Infrastructure
Country options: Need for ongoing linkage and

Country diversity: Need, interest, receptivity, resources engagement with other sectors/
Direction, path, timelines, priorities from WHO/other donors civil society
CRVS = civil registration and vital statistics
PHIN = Pacific Health Information Network
RMNCH = reproductive, maternal, newborn and child health
12
making.20 Some commonly used standards to assess an indicator are SMART and SPICED, acronyms
created using the first letter of their respective indicators (see Table 1). For example, the hospital
readmission rate for acute myocardial infarction (AMI) is a specific, measurable and result-oriented
indicator. However, it may be costly to collect the relevant data without a reliable, country-wide,
hospital-based data source. For some countries, this means that the indicator hospital readmission
rate may not be favourably assessed under the criteria achievable/attainable and time-bound.
Table 1. Criteria for SMART vs. SPICED Indicators
SMART Indicators SPICED Indicators
Specific: measures as closely as possible the Subjective: using informants for their insights
result it is intended to measure; disaggregated
data (where appropriate)
Measurable: quantitative (where possible); Participatory: involving a project’s ultimate beneficiaries, involving local staff
no ambiguity on what is being measured and other stakeholders
Achievable/Attainable: it is technically Interpreted and communicable: explaining locally defined indicators to other
possible to obtain data at a reasonable cost stakeholders
Result-oriented: reliable; general agreement Cross-checked and compared: comparing different indicators and progress,
over interpretation of the results and using different informants, methods and researchers
Time-bound: data can be collected frequently Empowering: allowing groups and individuals to reflect critically on their
enough to inform the progress and influence changing situation
the decisions
Diverse and disaggregated: seeking out different indicators from a range of
groups, especially men and women, to assess their differences over time
Source: Design, Monitoring and Evaluation for Peacebuilding (DME for Peace) website: http://dmeforpeace.org/.
Methods and analysis to support SDG and UHC monitoring

A number of methods and analyses can be used – alone or in combination – to assist the monitoring
process. Table 2 outlines some common methods and analyses and the main ways they can be used
to inform decision-making.
Table 2. Methods and analysis to support SDG and UHC monitoring

Method/analysis Context and Uses
Grouping and tracer indicators • Monitoring: cluster indicators in common themes and/or use fewer indicators
• Initial policy dialogue and discussions
Exploratory relationships • Guiding additional analyses
Regression analysis, including • Policy-making: better understanding of relationships to inform policy dialogue and evaluation
longitudinal data • Indicator selection
• Monitoring, including equity-focused monitoring
Qualitative analysis • Logic models/relationships
• Policy-making
• Combining data and information from multiple sources
Province-/district-level analysis • Building/understanding relationships
• Assessing health inequities
• Defining country monitoring framework
Qualitative/quantitative • Logic-models/relationships
approaches (expert panel/ • Indicator selection
consensus – Delphi method) • Policy-making
20
ibid.
13
The first approach attempts to simplify the monitoring burden. Indicators may be grouped using
factor analysis – a statistical technique that clusters indicators under a common theme (for example,
NCDs). In this situation, policy interventions targeting these common themes may be more effective
as the multiple indicators are statistically related. Similarly, tracer indicators are one or a group of
indicators that provide a good picture of some or several aspects of the health-care system. For
instance, hypertension (high blood pressure) can be treated in primary and community care, and
admission to hospital for hypertension may indicate problems with access to and quality of primary
care. Hospital admission rates for hypertension and other ambulatory care-sensitive conditions can
then be used to trace/track/monitor access to and quality of primary care.
Exploratory relationships and regression analysis can help to inform and guide policy dialogue
and discussion by showing how multiple factors relate to each other, and by identifying factors
that are likely to have the greatest impact on health outcomes. These statistical techniques may
help select different strategies for different programmes. For example, child immunization is an
effective strategy that contributes to minimizing child mortality; therefore, regression analysis is
likely to find stronger relationships in this area. On the other hand, the factors that relate to good
nutritional outcomes are likely to be too complex to be uncovered through regression analysis.
Qualitative techniques are most valuable for understanding health relationships that cannot be
measured through quantitative approaches. For example, gathering information from communities
and families can help us understand why access to primary care is problematic in certain areas. The
same information can be used to adjust policy and resource allocation and, if regularly collected,
can be used to monitor progress in access to primary care.
Provincial- or district-level analysis may be used, combining data from multiple sources so that
relationships between factors can be shown within an individual country. For example, health
worker density, socioeconomic status and education can be measured at the province or district
level and used in a regression model to understand how they relate to the proportion of births
attended by skilled personnel. Indicators at this level can also be used to assess health inequities.
The last method in Table 2 relates to the use of mixed quantitative/qualitative approaches such as the
Delphi method. The Delphi method is a systematic, structured technique used to arrive at an expert
consensus; it may have a number of applications during the monitoring process. Expert consensus
can be used to prepare a country’s monitoring framework, including the selection of indicators, to
clarify logic models and relationships, and to identify policy changes needed to improve progress
towards the SDGs and UHC.
14
4.2 How can countries use logic models to support SDG and UHC monitoring?
Logic models provide a rationale for identifying areas for policy intervention and help ensure that
policies and actions are based on evidence. Logic models focus on a sequence of relationships
in order to understand the process by which resources and inputs may contribute to expected
changes or results (Box 1). Through this process, a country can assess whether an initiative is being
implemented as planned, if it is leading to improvements, and whether it is necessary to adjust
interventions that are not effective.
Box 1 What is a logic model?

A logic model is also known as theory of change and is typically used to evaluate the effectiveness of a programme. The figure
below presents the key elements of a logic model. Input indicators measure the human, physical and financial resources involved
in a programme or system. Process indicators measure ways in which programme (or system) services and goods are provided.a
From a health system perspective, inputs and processes capture the foundational elements (for example, health workforce,
essential medicines) as they form the basis for a proper functioning of the system, delivering a range of quality health services.
Output indicators measure the quantity of goods and services produced and, when compared with the inputs, indicate the
efficiency of production.a Outcome and impact indicators capture all the effects of health care on patients and populations,
including changes to health status, knowledge and behaviour, as well as patient satisfaction and health-related quality of life.b
Appendix 4 categorizes all 88 indicators from the Regional Monitoring Framework according to the logic model.
Inputs/Processes
Outputs Outcomes Impacts
(Resources)
Planned activities and interventions Expected results

a
Horsch K. Indicators: definition and use in a results-based accountability system. Cambridge: Harvard Family Research Project; 1997 (http://
www.hfrp.org/publications-resources/browse-our-publications/indicators-definition-and-use-in-a-results-based-accountability-
system; accessed 22 August 2017.
b
Donabedian A. An introduction to quality assurance in health care. New York: Oxford University Press; 2002.
Source: Adapted from Designing a results framework for achieving results: a how-to guide. The World Bank Group. Washington DC, 2012. (https://siteresources.
worldbank.org/EXTEVACAPDEV/Resources/designing_results_framework.pdf)
The use of logic models in SDG and UHC monitoring should improve critical thinking in policy
development. The logic model helps to identify problems and their causes, to define targeted
solutions/interventions, and to formulate, implement and evaluate policy changes. Although
typically presented as a linear process, in practice progress through any sequence of relationships
may not necessarily be linear. Countries need to be aware that this situation may affect policy-
making as well as evaluation of the effect of policy change. Countries are also encouraged to use
additional techniques, such as qualitative analysis, to understand aspects of progress not captured
through the logic model. The use of a linear logic model should help organize complex interactions
and guide initial policy discussion.
In 2016, WHO Regional Office for the Western Pacific developed an action framework for UHC21 in
which the use of a logic model approach from input to impact was highlighted (Figure 5).
21
2017.)
15
The Western Pacific Region logic model captures crucial health sector inputs and interventions, as
well as health-related initiatives from other sectors that improve coverage of health services and
financial risk protection, in order to attain the highest possible level of well-being and health for
populations. The model is linked to the regional UHC action domains through the five essential
health systems attributes: quality, efficiency, equity, accountability, and sustainability and resilience.
The regional logic model in Figure 5 provides a template to guide countries in their own analytical
process. Targets and indicators from a country’s monitoring framework can be organized according
to this model. Countries may choose to take a broad perspective to choose interventions for multiple
changes in the health system or a narrower perspective to target particular populations, patient
groups or conditions. Some examples are given below.
Figure 5. Western Pacific Region logic model
INPUTS AND PROCESSES OUTPUTS

HEALTH SECTOR HEALTH SERVICE DELIVERY HEALTH FINANCING
• Governance • Medicines and • Availability and readiness • Out-of-pocket spending
• Health financing technologies • Effectiveness and safety • Government investment
• Health workforce • Health information • Accessibility in health
• Service delivery • Surveillance systems • Efficiency
TOR
• People-centredness
OTHER SECTORS
• Governance and policies
EC
S MUNIT HEALTH-RELATED INTERVENTIONS
AND SOCIAL DETERMINANTS
• Financing
C OM I ES
TH
• Education • People-
• Infrastructure and
HEAL
• Food and nutrition centredness

technologies • Infrastructural and • Housing
environmental • Employment
INDIVIDUAL interventions
AND
HOUSEHOLD AND SOCIAL IMPACT FAMILIES HOUSEHOLD HEALTH-RELATED
RS
• Poverty impact
OC EXPENDITURE
KS
IAL N ET W OR
• Health security
S
• Catastrophic expenditure
CT O
• Social inclusion
E R SE HEALTH SERVICE LIFESTYLE FACTORS

POPULATION HEALTH
• Well-being
HEALTH SYSTEM
• Quality OTH COVERAGE
• Promotive
AND PRACTICES
• Health literacy
• Life expectancy • Efficiency • Preventive • Substance use
• Mortality • Equity • Curative • Nutrition
• Morbidity • Accountability • Rehabilitative • Physical activity
• Disability • Resilience • Palliative • Safe practices
IMPACTS OUTCOMES
Source: Universal health coverage: moving towards better health. Action framework for the Western Pacific Region. Manila: WHO Regional Office for the Western
Pacific; 2016.
Example 1
A country targets the input element health information system as a strategic priority and decides
to focus on strengthening coverage of birth and death registration. This would improve data and
therefore decision-making in many areas of the health system, including assessment of children’s
needs, access to and outputs of care, and outcomes for individual health conditions, for groups
of patients and for the overall population (for example, for malaria and hepatitis mortality rates).
The data would help with setting policy priorities and planned actions in the five UHC action
domains. This sequence of potential improvement follows the overall logic approach of the model,
contributing to advances in individual and population health.
16
Example 2
A country targets equity-focused access to essential medicines and technologies and improved
distribution and composition of the health workforce as strategic priorities. Improvements in these
system inputs may contribute to a sequence of positive changes, including increased coverage of
and access to health services, and better quality and improved efficiency of the services provided.
These improvements would also be expected to benefit equity in health outputs and outcomes.
Example 3
A logic model can guide monitoring activities in particular focus areas. Figure 6 presents an example
to support health policies and interventions in children’s health. The example uses indicators from
the core SDG and UHC reference list to show how countries can apply both the SDG and UHC Regional
Monitoring Framework and a logic model. Additional indicators may be included to reflect the full
pathway towards children’s health.
Figure 6. Example of the Western Pacific Region logic model applied to children’s health
Equity-focused service delivery:

• Health worker density and distribution • Skilled birth attendance
• Availability of essential medicines • Institutional deliveries
• Health facilities with basic water supply • Newborn receiving essential newborn care
•
•
Health facilities with basic sanitation
Birth and death registration coverage
EC TOR • People-centredness
S MUNIT
C OM I ES
TH
HEAL
Disaggregated by age, sex,

place of resi-dence, socio-
INDIVIDUAL economic status
AND
FAMILIES
RS
OC
KS
IAL N ET W OR
• Children <5 stunted
S
CT O
• Children <5 wasted
SE
• Children <5 overweight
• Under-5 mortality
• Neonatal mortality
OTH E R •
•
•
Low birth weight
Care-seeking for symptoms of pneumonia
Exclusive breast-feeding
• Full immunization
• Measles immunization
place of residence, socio-
economic status
IMPACTS OUTCOMES
In this example, improvements in health worker density and distribution, availability of essential
medicines and increased number of health facilities with functioning water and sanitation will all
contribute to higher rates of skilled birth attendance, institutional deliveries and essential newborn
care. These service outputs in turn all contribute to improved outcomes. The determinants of some
child health outcomes are not currently included in the Region’s core reference list of indicators.
Where countries identify these gaps, they can propose additional indicators to help define their
own pathways. The overall logic of the model assumes that changes in most of the indicators listed
in the example will reflect changes in under-5 and neonatal mortality rates.
For policy development, each country should undertake additional analyses and discussions,
including equity analysis and cost-effectiveness analysis of interventions. For example, if health
worker density and distribution are highly uneven across the country, strategies or mechanisms to
17
incentivize health workers to relocate to underserviced areas may be investigated and developed.
After the agreed policy has been formulated and implemented, indicators will allow monitoring
and evaluation to assess whether the intervention improved the density and distribution of health
workers and if there was consequent improvement in outputs and outcomes. At this point, the
country can reassess the problem areas initially identified and, if necessary, modify their policy and
interventions for children’s health.
Example 4
The same logic approach can be applied to specific diseases. For example, for malaria in poor, rural
areas, the indicators in Figure 7 could be used to monitor progress towards malaria-related outputs
and outcomes. In this example, health policies and interventions should target those areas with
evidence showing high incidence of malaria or high risk of widespread occurrence of the infection.
Actions might include financial and non-financial incentives for health workers to relocate to these
areas, and policies to improve procurement, distribution and management of essential medicines
to ensure they are available when needed.
Measures of quality and efficiency (in the output box) would reflect improvements in availability of
essential medicines and in the density and distribution of health workers. They might also reflect
other actions directly targeting hospitals and the health-care system, as described in the Western
Pacific UHC action framework.22 In this example, better quality and more efficient care should lead
to reduction in the incidence of malaria and in malaria-associated mortality in the targeted areas.
Figure 7. Example of the Western Pacific Region logic model applied to malaria in poor rural areas
• Availability of essential medicines Equity-focused service delivery:

• Health worker density and distribution • Service utilization (outpatient visits)
• Hospital admission and readmission rates
• Hospital mortality rate
EC TOR • Hospital average length of stay
S MUNIT For malaria patients

Health policies
C OM I ES
TH
and Interventions target

HEAL
malaria in poor rural areas Disaggregated by age, sex,

place of residence,
INDIVIDUAL socio-economic status
AND
FAMILIES
RS
OC
KS
IAL N ET W OR
S
CT O
• Malaria
S E
incidence rate
• Malaria OT HE R
mortality rate

place of residence, socio-
economic status
IMPACTS OUTCOMES
22
2017.)
18
Logic models can support critical thinking throughout the policy development process. The
examples presented in this section show a starting point for this line of analytical thinking. However,
they would be complemented by additional techniques and tools, as described in Table 2, to better
assess the extent of the health issues.
4.3 How can countries conduct equity analysis and monitoring?

In the SDG agenda, equity focuses on the poor and disadvantaged, with the aim of leaving no one
behind. This means ensuring that all people can obtain the health services they need without facing
financial hardship or other barriers – usually related to the social determinants of health. Equity
analysis aims to identify who is and is not being reached and why certain populations are being left
behind.
A necessary prerequisite for an equity-oriented health sector is to identify clearly where inequities
exist and then monitor how these inequities change over time.23 One approach to equity analysis is
to disaggregate data using common attributes as stratifiers. These may include the following:
yy Demographic: age, sex

yy Socioeconomic status: wealth, education
yy Place of residence: rural, urban
yy Geography: province, district, municipality
yy Other characteristics: disability, race, migratory status, ethnic minorities.
Monitoring such disaggregated data over time helps to assess progress towards meeting the health
needs of those at risk of being left behind. Double disaggregation can also be conducted, meaning
the filtering of data using two criteria, such as wealth and place of residence. Double disaggregation
can help identify disadvantaged populations, such as those with low coverage of essential services.
Within the Region, six countries can already provide data on selected aspects of health and well-
being disaggregated by sex, education, place of residence, subnational region and income level
(quintile/decile). These are Cambodia, the Lao People’s Democratic Republic, Mongolia, the
Philippines, Vanuatu and Viet Nam. The data come from household-based surveys such as the
Demographic Health Survey (DHS), the Multiple Indicator Cluster Survey (MICS) and the Living
Standards Measurement Study. However, for a number of indicators and countries, there are limited
data for equity analysis. Expanding the use of household surveys and/or conducting other regular
studies may be the only option for many countries to be able to address this analytical need.
The use of routinely collected administrative data can also support equity analysis. Data from health
facilities and from vital registration, for example, may show geographic differences in mortality
and morbidity by using district and/or subdistrict. Figure 8 presents an example of equity analysis
using routinely collected data for stratification. This example, building on that used in Section 4.2
on children’s health, uses double stratification to identify four population groups, including urban
poor and non-poor, and rural poor and non-poor.
Figure 8 shows clear inequities in inputs, outputs and outcomes given the variation in values of the
indicators across all four population groups in 2017. When comparing urban non-poor with rural
poor, there are significant differences in values for all indicators, with a clear gradient when the other
23
19
two population groups are included. In urban non-poor areas, close to 90% of health facilities have
functioning water supply and sanitation, while in rural poor areas, this percentage is much lower at
40%. There are similar gaps for health worker density and distribution, skilled birth attendance and
under-5 mortality. This information provides evidence to initiate policy dialogue, to discuss policy
options and to consider which cost-effective interventions should be introduced or strengthened
in the poor rural areas.
This example also shows how values for these indicators may change over time. Improvements in
health facilities with functioning water supply and sanitation and adequate health worker density
are greater in rural areas, likely reflecting efforts to target these essential attributes of a health system
in disadvantaged populations. As a consequence, skilled birth attendance and under-5 mortality
also show greater improvement in rural areas.
This type of equity analysis provides a valuable layer of information to inform the policy development
process, both for identifying problem situations and for evaluating the effect of policy changes
Figure 8. Hypothetical example of equity-focused analysis

Inputs:
• Health-care facilities with basic water supply • Health-worker density and distribution
and sanitation (%) (per 10 000 population)
100% 60
90%
80% 50
70%
40
60%
50% 30
40%
30% 20
20%
10
10%
0% 0
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Rural poor Rural non-poor Rural poor Rural non-poor

Urban poor Urban non-poor Urban poor Urban non-poor
Outputs and Impacts:

• Skilled birth attendance (%) • Under-5 mortality rate (deaths
per 1 000 live births)
100% 70
90% 60
80%
70% 50
60% 40
50%
30
40%
30% 20
20%
10
10%
0% 0
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Rural poor Rural non-poor Rural poor Rural non-poor

Urban poor Urban non-poor Urban poor Urban non-poor
Source: WHO
20
on the targeted disadvantaged groups. Countries are expected to incorporate this type of equity
analysis when monitoring and reviewing progress towards the SDGs and UHC.
Member States may wish to complement equity analysis with other equity-oriented approaches,
including gender- and human rights-based analyses. In combination, gender, equity and human
rights-based analyses provide complementary and mutually reinforcing lenses for analysis. All three
types of analysis draw on both quantitative and qualitative data.
Gender analysis24
Gender analysis in health examines how biological and sociocultural factors interact to influence
the health of women and men, boys and girls. It can help to unpack women’s and men’s different
roles and activities, the norms that define their behaviours, relations between men and women,
the resources they have access to and control over, and the constraints they face. Gender analysis
identifies, assesses and informs actions to address inequality that comes from: (1) different gender
norms, roles and relations; (2) unequal power relations between and among groups of men and
women; and (3) the interaction of gender with such other determinants as ethnicity, education or
income.
WHO has developed a number of tools to support gender analysis in health, including the gender
analysis matrix and gender analysis questions.
Human rights-based analysis (or HRBA analysis)25
The UN Statement of Common Understanding on Human Rights-Based Approaches to Development

Cooperation and Programming was adopted by the United Nations Development Group in 2003. It
stresses that human rights standards and principles – such as nondiscrimination, participation and
accountability – should guide all development cooperation and programming in all sectors and in
all phases of the project cycle.
There are several different approaches and tools for conducting HRBA. Common methods or steps
include causality analysis (unpacking the immediate, underlying and root causes of an issue),
role/pattern analysis (identifying rights-holder/duty-bearer roles and relationships) and capacity
gap analysis (understanding gaps in capacity, including responsibility/motivation/commitment/
leadership, authority and access to and control over resources).
A focus on the social determinants of health
The greater focus of the SDGs on disadvantaged populations will require Member States to
strengthen their emphasis on the connections between health and the broader social determinants
of health. Health either underpins or is affected by all of these factors through multiple, complex
and interrelated mechanisms. The SDG Agenda highlights the influence of the social precursors of
good health and hence the broader front on which health improvements must be tackled.
24
Gender mainstreaming for health managers: a practical approach. Geneva: World Health Organization; 2011 (http://www.who.int/gender-
equity-rights/knowledge/health_managers_guide/en/; accessed 22 August 2017).
25
The human rights based approach to development cooperation towards a common understanding among UN agencies. New York: United
Nations Development Group; 2003 (https://undg.org/document/the-human-rights-based-approach-to-development-cooperation-towards-
a-common-understanding-among-un-agencies/; accessed 22 August 2017); UN Common Learning Package on HRBA (http://hrbaportal.org/
common-learning-package-on-hrba). In: UN Practitioners’ Portal on HRBA website]. New York: United Nations Development Group; 2017
(http://hrbaportal.org/; accessed 22 August 2017).
21
For example, gender inequality typically results in lower school enrolment rates for girls than for
boys. In turn, poor education results in poorer health outcomes for girls and women themselves
and for their children and families. Similarly, disability, marginalization or ethnicity can compound
gender-based disadvantage and further limit access to health and other social services.
The complexities of these relationships and therefore of population health are summarized and
synthesized in the Commission on Social Determinants of Health (CSDH) conceptual framework for
action (Box 2). The CSDH framework can provide an extra layer of guidance in formulating a country’s
monitoring framework, for example, by overlapping the CSDH framework with existing logic models.
Improving health from the perspective of the broader social determinants of health will require
countries to take concerted and coordinated actions, and for the health sector to form partnerships
with various sectors and levels of government to identify critical entry points for effective actions.
Box 2 Commission on Social Determinants of Health (CSDH) conceptual framework
SOCIOECONOMIC AND
POLITICAL CONTEXT
Governance Material
Socioeconomic Position Circumstances
(Living and Working,
Macroeconomic Conditions, Food,
Policies Availability, etc.)
Social Class IMPACT ON EQUITY
Gender Behaviours and IN HEALTH AND
Social Policies WELL-BEING
Labour Market, Ethnicity (racism) Biological Factors
Housing, Land Psychological
Factors
Education
Public Policies Social Cohesion and
Education, Health, Social Capital
Social Protection Occupation
Culture and Income

Societal Values Health System
STRUCTURAL DETERMINANTS SOCIAL DETERMINANTS INTERMEDIARY DETERMINANTS

OF HEALTH INEQUITIES SOCIAL DETERMINANTS OF HEALTH
Source: Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2. Geneva:
World Health Organization; 2010.
4.4 How can countries use monitoring data effectively in policy- and decision-making?
Effective use and communication of monitoring data are fundamental to driving change at different
levels of the health system. Each country will need to ensure that the content (including level of
detail) of their action plan and the formats for reporting health information are tailored to the needs
of different audiences from across the community and the health system.26 The action plan should
26
Review of Australia’s health system performance information and reporting frameworks. Australian Government Department of Health
[website]. Canberra: Government of Australia; 2017 (https://consultations.health.gov.au/research-data-and-evaluation-division/review-of-
australia-s-health-system-performance-in/; accessed 22 August 2017).
22
make use of analytical and interactive tools to communicate the monitoring results to different
audiences. Likely audiences will include the general public, patients and their families, care providers,
community and other advocates, the media, public and private insurers, local and international
donors, health-care purchasers, professional health provider associations, policy-makers at all levels
of government, researchers, medical and nursing schools, and regulatory bodies, associations and
societies.
Overall, the general public will require the least detail; the purpose of reporting to the public is
to inform consumers, promote transparency and support research. Audiences at points of care
may require the most detail, as the aim is to show service improvements and to discuss and guide
further progress. The purpose of reporting to policy-makers at different levels is to indicate strategic
direction and the level and distribution of funds and other resources, and to inform policy changes
to improve the health system.27
For example, policy-makers may be told how cervical cancer screening rates vary across population
groups and regions to show that action is needed so that no one is left behind. Patients, families
and community advocates may be less interested in the proportion of women screened but more
in whether screening is available where they live and whether the service is free. Similarly, regional
variation of foundational aspects of health system development may only be relevant for policy-
makers and, depending on the specific issue, for health-care purchasers and insurers. From the SDG
and UHC Regional Monitoring Framework, indicators for these foundational aspects include those
capturing health worker density and distribution, birth and death registration, and the number and
proportion of health facilities with functioning sanitation and water.
An important audience is those who influence policy- and decision-making. Within government,
this may include the minister and/or deputy minister of health, internal or external committees
and organizations advising the ministry on policy, and legislative assemblies or parliamentary
committees that approve government funding or changes in regulations, acts or laws. Depending
on the degree of decentralization of health services and financing in a country, this group may also
include provincial or district ministers of health, city mayors, and/or directors of public health units.
Within this decision-making group, the type of information to be provided may also vary. Up to
the level of minister, associate minister or deputy minister, the evidence should clearly show the
nature of the problem, main options to address the problem, including costs and benefits, and
a recommendation for the best option. For example, if hospital access is a priority, the minister’s
briefing should incorporate an equity analysis and a logic model assessing not only the problem but
also its impact on the health system and on the health status of key population groups. Although
several options for policy intervention can be presented, the minister may expect a recommendation
on the intervention likely to have the greatest impact and to reach the most disadvantaged groups.
In some cases, policy development may involve legislative action. In this situation, the evidence
and information should only point to the problem, the effect on the population, and the option
recommended.
If care providers are directly involved in a particular policy priority, detailed data and information
will be very helpful when engaging in dialogue with them. For example, if a policy aims to target
high rates of postoperative sepsis, then detailed stratification and a logic model-based analysis
27
Nous Group. Public consultation summary report. For the Australian Ministers’ Advisory Council (AHMAC). Australian Government Department
of Health [website]. Canberra: Government of Australia; 2017 (https://static1.squarespace.com/static/584f45a59de4bbb88e87f673/t/58dc4ae50
3596edd8bf1209a/1490832104406/Public_Consultation_Summary_Report.pdf; accessed 22 August 2017).
23
should help to clarify the root causes of the problem and to define solutions, in collaboration with
medical and nursing staff, professional associations and hospital managers.
Monitoring data should be available to all audiences. This involves posting clear, concise information
on various publicly accessible platforms, including the reporting of SDG progress, in order to increase
transparency and community participation, and to promote the accountability of government,
donors, and development and nongovernmental partners.
4.5 What mistakes should countries avoid when monitoring SDG and UHC?
The following scenarios are reminders to avoid the common barriers to implementation of
monitoring for SDGs and UHC.
1. (Do not) treat monitoring as an isolated activity
Each country should build a monitoring framework that suits its own priorities and needs and can
support policy- and decision-making. The SDG and UHC monitoring framework, including equity
analysis and monitoring, should be developed in coordination with the policy development process.
This will ensure that the indicators will be selected according to policy priorities and needs and that
they will measure progress in relevant areas and especially where policy changes and interventions
are being considered. SDG and UHC monitoring will be adapted to meet new developments and
directions arising from the policy development process.
2. (Do not) collect excessive, unusable data and information
Data should be collected only for those indicators selected for SDG and UHC monitoring, linked to
clear strategic and policy directions. Try to avoid selecting indicators where there are no data, as
significant resources may be needed to build them. A country’s SDG and UHC monitoring framework
should consolidate all existing information frameworks and become the overarching framework for
health system performance information and reporting. The aim of a consolidated framework is to
direct actions towards tracking indicators for health and its determinants – including equity – using
data from a range of sources across health and other sectors. These sources include facility data,
population-based surveys, surveillance data, civil registration and vital statistics, and relevant data
from stakeholders beyond government.
An overarching monitoring framework would create a single database on a country’s health system
performance and allow for information gaps to be identified and addressed in a coordinated manner.
It would reduce the cost and administrative burden by streamlining processes and roles in health
system reporting.28 The Healthy Islands Monitoring Framework is a good example of streamlining
efforts to lead and unify monitoring of priority health issues (Box 3), as is Australia’s process of
consolidating multiple health performance information and reporting frameworks (Box 4).
28
Ibid.
24
Box 3 Healthy Islands monitoring framework and indicators

In 1995, the Pacific health ministers declared their vision of Healthy Islands in the Yanuca Island Declaration. The Declaration’s
comprehensive and integrated approach has served to protect and promote health in the Pacific by addressing priority health
issues, including both NCDs and lingering and emerging and re-emerging infectious diseases.
The recently developed Healthy Islands Monitoring Framework comprises 52 mandatory indicators (36 core and 16 complementary)
and 26 optional indicators from which countries can make their selections based on national priorities and reporting capacity. The
indicators were identified based on specific criteria, including the availability of subregional and national information to assess
20-year trends, as well as of agreed collection methodologies or secondary data sources, and the ability to chart progress on the
Healthy Islands descriptors and the five elements of the Healthy Islands vision.
The Framework provides institutional mechanisms and opportunities to better measure, report and share data, including on
indicators for the five Healthy Islands elements and priority actions. It enables the use of regional health governance mechanisms
to report progress regularly and share success stories to help build national capacities.
Source: Regional Action Agenda on Achieving the Sustainable Development Goals in the Western Pacific. Manila: WHO Regional Office for the Western Pacific;
2016.
Box 4 Australia’s health system performance information and reporting framework

In August 2016, the Australia Health Ministers’ Advisory Council commissioned a review of Australia’s multiple health system
performance information and reporting frameworks. The review proposed a combined whole-of-system performance framework
comprehensive enough to serve as a single source of Australia’s health system performance.
The benefits of a single framework include better identification of information gaps that can be addressed in a coordinated manner,
and reduction in resource costs and the administrative burden by streamlining processes and roles in health system reporting.
The review emphasizes the need for a national model for data collection, supply and use. The benefits of this approach include
improved consistency in and efficiency of data collection; a reduction in duplication of data collection, analysis and reporting; more
sophisticated and targeted analyses; and more timely, meaningful and tailored reporting of data and findings at all levels of the
system as well as to consumers and the general public.
A tiered reporting framework was proposed to ensure health data are effectively used. The audiences include the public,
jurisdictions, regions and points of care, with more detailed data for audiences at points of care. The figure below presents a
simplified version of the framework.
Purpose of the Framework

Determinants of Health Health System Performance Health Status
• HEALTH BEHAVIOUR • EFFECTIVENESS • HEALTH CONDITIONS
• COMMUNITY AND • SAFETY • HUMAN FUNCTION
SOCIOECONOMIC FACTOR • RESPONSIVENESS AND • WELL-BEING
• ENVIRONMENTAL FACTORS CONSUMER SATISFACTION • DEATHS
• BIOMEDICAL FACTORS • CONTINUITY OF CARE
• ACCESSIBILITY
• EFFICIENCY AND
SUSTAINABILITY
Transparency
Equity
Source: Nous Group. Public Consultation Summary Report. For the Australian Ministers’ Advisory Council (AHMAC).
25
3. (Do not) immediately select all the indicators of the SDG

and UHC Regional Monitoring Framework
Attempting to immediately collect data and information on all indicators from the SDG and UHC
Regional Monitoring Framework may divert effort from those requiring immediate attention as a
priority. Each country is expected to identify high-priority targets and indicators, taking into
consideration the country realities, characteristics, challenges and capacities. For some indicators,
there are no data currently available and focusing on them unnecessarily may hinder progress in
monitoring areas with known, real health needs. Indicators should be selected in line with each
country’s strategic plan for health system development. This will require analyses similar to those
presented in this report, including equity analysis, policy dialogue and discussions, and careful
consideration of the country’s capacity to engage in all aspects of indicator development.
One way to address the challenge of limiting the number of indicators is by using tracer indicators.
Tracer indicators are typically a smaller, methodologically identified set of indicators that provide a
good picture of more than one aspect of the health system. For example, hospital readmission rates
may be used to trace both the overall quality of the care provided in hospitals and also access to and
quality of primary care.
4. (Do not) select SDG and UHC indicators to follow donor funding exclusively
While indicators should reflect the development interest of donors, this should not be the only
focus of a country’s monitoring framework. Ideally, the framework and indicators are based on the
country’s priorities and needs. Indicators that are important to donors should be incorporated into
the framework to the extent possible, without diverting attention to specific donor-linked aspects
of a country’s strategic health plan. Typically, donor funding is linked to a country’s health priorities.
5. (Do not) forget to systematically identify where health inequities exist
One important step to support equity-focused data collection and analysis is to disaggregate
indicators according to commonly used stratifiers, as outlined in Table 3. Some stratifiers are
important for a large number of indicators (for example, sex, age, wealth quintile), while others may
be relevant only for a few indicators (such as provider type). The systematic identification of areas
and community groups that are either disadvantaged or vulnerable becomes the basis for refining
policies and targeting programmes to improve equity in health services and outcomes.
Table 3. Commonly used stratifiers available for disaggregation of SDG and UHC data
Stratifiers
Age, mother’s age
Disability status
Education, maternal education
Ethnic group, race, indigenous groups
Facility type (e.g. public/private), provider type, health subsector
Key populations (e.g. HIV status, transgender, prisoners)
Marital status
Place of residence, urban/rural, subnational district, geographic location
Sex, sex of household head
Socioeconomic status, wealth quintile, employment status
26
5. INDICATORS, DATA AND DATA SOURCES
This chapter presents an overview of technical information relevant to the development, analysis
and interpretation of indicators, including the collection, measurement and reporting of data.
5.1 Sources of health information

There are many sources of health information, each with strengths and weaknesses. The scope and
availability of each source may vary across countries. Effective SDG and UHC monitoring requires
each country to make the best use of all data sources available.
There are two broad categories of data sources: (a) population-based; and (b) institution-based
(Figure 9). Surveillance systems, which often combine population-based and institution-based data,
are sometimes classified as a third category.29
Figure 9. Examples of type of data sources for indicator development
Institution-based sources
Population-based sources Surveillance
(administrative data)
• Censuses • Resource and service records Examples:
• Vital registration systems • Individual records • Outbreak and disease
• Household surveys • Payment and/or surveillance
• Setting-based surveys insurance-based records • Sentinel surveillance
• Risk factor surveillance
• Demographic surveillance
Source: Handbook on health inequality monitoring: with a special focus on low- and middle-income countries. Geneva: World Health Organization; 2013.
Qualitative information
Participatory and qualitative methods of data collection are not extensively used to build
indicators. However, Member States are encouraged to use them together with quantitative
approaches to enhance understanding of progress towards SDGs and UHC and improve policy
and accountability. Qualitative information can help show the complexity of the agenda and offer
insights into why progress is or is not being made. For example, people, families and communities
themselves are an important source of information as well as recipients of information,
especially from the perspective of responsiveness and accountability. Through focus groups,
they can provide information on demand-side issues that more disadvantaged subpopulations
disproportionately face – often linked to adverse social and environmental determinants as well as
gender norms, roles and relations.30
29
30
World health statistics 2017: monitoring health for the SDGs. Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstre
am/10665/255336/1/9789241565486-eng.pdf; accessed 22 August 2017).
27
Population-based data sources
Population-based data sources provide either information on every individual in a population or

on a representative sample of the population.31 The three best-known sources of data within this
category are censuses, vital registration systems and household surveys.
Censuses
In most countries, national population and household censuses are conducted every 10 years. The
census should be carried out at a well-defined point in time and at regular intervals, in order to
make comparable information available in a fixed sequence.32 Census data provide information
on the size, composition and spatial (geographic) distribution of the population, as well as key
demographic and socioeconomic characteristics, including age, sex, socioeconomic status and
race or ethnicity. These characteristics can all be used as stratifiers for monitoring the degree and
distribution of inequity.33
A population census provides data either for the whole population or for a large representative
sample of the population, which allows the estimation of results for relatively small geographic
areas and population subgroups. However, the general census typically includes little direct health-
related information. Despite this limitation, census data can support health equity analysis through
linkages with other sources of health information. This use of census data to improve health-related
analysis is a common practice in high-income countries.
In low- and middle-income countries, the census may be strengthened by including small-area
identifiers, such as postcodes. This allows for equity analysis by linking census data with health-
related sources, including vital statistics, surveillance data and administrative health facility
data. While individual-level identifiers are ideal for data linkages, such small-area identifiers – if
standardized across different data sources – offer an alternative, more easily implemented option.
Vital registration systems

In general, the civil registration and vital statistics (CRVS) system records the births, deaths, marriages
and divorces in a population. Countries with a strong CRVS system can reliably determine and track
mortality rates, life expectancy and cause-of-death data at the population level.34 These data play a
fundamental role in planning and monitoring of public health activities and outcomes. For example,
an effective CRVS system can help ensure enrolment of every child into immunization programmes,
and indicators can be tracked to monitor the prevention of avoidable diseases. CRVS data are also
very valuable for equity analysis.
The CRVS system is a multisectoral undertaking usually managed by the government’s Statistics
Office or Bureau of Statistics. Those involved in the recording, notification and registration of vital
events include citizens, doctors and other health workers, police, clerics, population registries
and ministries of health. The system is used by many groups, including health, tax, planning and
other government authorities and the policy-makers of many sectors. The involvement of multiple
31
32
Suharto S. Complementary sources of demographic and social statistics. Reported in: Symposium on Global Review of 2000 Round of
Population and Housing Censuses: Mid-Decade Assessment and Future Prospects; New York, 7–10 August 2001. New York: United Nations
(http://unstats.un.org/unsd/demog/docs/symposium_03.htm#_Toc7427911; accessed 22 August 2017).
33
34
Civil registration and vital statistics 2013: challenges, best practice and design principles for modern systems. Geneva: World Health
Organization; 2013 (http://www.who.int/healthinfo/civil_registration/crvs_report_2013.pdf?ua=1; accessed 22 August 2017).
28
INDICATORS, DATA AND DATA SOURCES
institutions and actors makes coordination and governance a key challenge in building effective
CRVS systems.35
Until recently, CRVS systems in low- and middle-income countries have been largely paper-based
and manually managed, but efforts are now being made to strengthen the systems with computer-
and mobile-based technologies.36 For example, health institutions in many countries can now
transmit name-based birth and death records electronically to the national civil registry office.
CRVS systems in many low- and middle-income countries do not yet provide satisfactory coverage
nor adequate quality in the methods for aggregating, using and sharing data. Frequency of data
availability, time delays and under-reporting remain significant problems in some countries.37 There
is, however, some global momentum to improve CRVS in countries where national coverage is
relatively weak.38
Household surveys
Household surveys are usually conducted to assess the status of a specific topic or topics at the
national level. They are typically administered by country governments or national research bodies
with the assistance of international aid agencies or nongovernmental organizations. Many countries
have instituted a programme of periodic surveys, which may include annual or quarterly labour
force surveys or annual surveys of cost of living, including socioeconomic, income and expenditure
information. Ad hoc household surveys may also be conducted to meet specific statistical data
needs. These ad hoc surveys may satisfy immediate needs, but do not provide a framework for a
continuing database and/or time series.
Continuing periodic surveys, on the other hand, are used to investigate a highly important
phenomenon that needs to be monitored frequently. All household survey programmes should
be part of the country’s overall integrated statistical data collection system, including censuses and
administrative records, so that the overall needs for statistical data can be adequately met.39
Usually, household surveys cover a large number of indicators on a specific theme, such as
reproductive, maternal and child health, or nutrition. Household surveys can provide specific
information on health topics of interest in low- and middle-income countries, in conjunction with
socioeconomic, demographic and geographical information at both the individual and household
levels.
Household surveys are designed to draw information from a sample of the population rather than
from every individual within the population. While the surveys generally have a sample size large
enough to draw precise conclusions about the overall population, they may not be sufficient for
35
Ibid.
36
Kariyawasam N, Weerasekera V, Dayaratne M, Hewapathirana R, Karunapema R, Bandara I. eIMMR: the future of health statistics in Sri Lanka.
Sri Lanka J Bio-Med Inform. 2011;1(Suppl 14):1.
37
An overarching health indicator for the Post-2015 Development Agenda. Brief summary of some proposed candidate indicators. Background
paper for Expert Consultation 11–12 December 2014. Geneva: World Health Organization; 2014 (http://www.who.int/healthinfo/indicators/
hsi_indicators_SDG_TechnicalMeeting_December2015_BackgroundPaper.pdf; accessed 22 August 2017).
38
Strengthening civil registration and vital statistics for births, deaths and causes of death. Resource kit. Geneva: World Health Organization;
2013 (http://apps.who.int/iris/bitstream/10665/78917/1/9789241504591_eng.pdf; accessed 22 August 2017); Phillips DE, AbouZahr C, Lopez
AD, Mikkelson L, Savigny D, Lozano R, et al. Are well functioning civil registration and vital statistics systems associated with better health
outcomes? Lancet. 2015;286(10001):1386–94. doi: 10.1016/S0140-6736(15)60172-6; Ooman N, Mehl G, Berg M, Silverman R. Modernising vital
registration systems: why now? Lancet. 2013;381(9875):1336–7. doi: 10.1016/S0140-6736(13)60847-8.
39
Suharto S. Complementary sources of demographic and social statistics. Reported in: Symposium on Global Review of 2000 Round of
Population and Housing Censuses: Mid-Decade Assessment and Future Prospects; New York, 7–10 August 2001. New York: United Nations
(http://unstats.un.org/unsd/demog/docs/symposium_03.htm#_Toc7427911; accessed 22 August 2017).
29
valid disaggregation of information for all population subgroups. In such a situation, the survey
design may compensate by extra sampling in certain minority subgroups or regions.
Household surveys are often the prime instrument to collect data on equity and may be a rich source
of disaggregated data on coverage of health services and financial protection. However, they do
present some challenges.40 The data for service coverage and financial protection often come from
different surveys, including DHS, MICS and others, such as household budget surveys.
The comparability of results may also be affected by differences in the survey design, questions
or implementation. For example, health expenditures reported in surveys focusing on health
tend to be higher than those reported in surveys where health is only one of many items under
consideration. In the Western Pacific Region, China collects health expenditure data from its
national health service surveys, whereas Cambodia, the Lao People’s Democratic Republic,
Mongolia, the Philippines and Viet Nam use socioeconomic surveys or income and expenditure
surveys. Additional challenges include the recall periods and survey years, which may vary across
countries.
Despite these challenges, household health surveys should be introduced in countries where they
are not currently conducted, with resources to ensure they occur on a regular basis. Household health
surveys can potentially be expanded to cover topics where data are often unavailable, such as NCDs
and injury.41
Setting-based survey
Setting-based surveys should also be considered a population-based source if they collect
information from a representative sample of the population. For example, school-based surveys can
identify specific health issues affecting the school-going population at a particular point in time,
covering a random sample of schools. The benefit of setting-based surveys lies in the convenience
of having the target population in one place, which allows the use of different strategies to maximize
the response rate.
Institution-based data sources
Institutions produce administrative data in the course of government and health system activities,
and these data can provide many useful statistics, for example, derived from reports based on
hospital records. The three main sources of data in this category are: resource and service records,
individual records, and payment or insurance-based records.
Resource and service records

Resource and service records include internally kept records describing the activities of the
institution. The data are typically reported at the institution level and can be aggregated to higher
reporting levels from the community level up to the national level. The institutions may include
primary care centres and other clinics for ambulatory patients, public health units or centres,
hospitals and other health-care institutions, laboratories, and local, provincial or federal health
authorities and governments.
40
Hosseinpoor AR, Bergen N. Area-based units of analysis for strengthening health inequality monitoring. Bull World Health Organ.
2016;94(1):856–8. DOI: 10.2471/BLT.15.165266.
41
Hosseinpoor AR, Bergen N, Schlotheuber A. Promoting health equity: WHO health inequality monitoring at global and national levels. Glob
Health Action. 2015; 8(1):29034. doi: 10.3402/gha.v8.29034.
30
For example, statistics from 10–15 primary care centres within a community can be aggregated to
the community level. Then statistics from multiple communities can be aggregated to the provincial
or national level. For some service types, higher-level reports may also be disaggregated. For
programmes run directly by a local government, statistics may be produced at lower levels (such as
primary care centres or hospitals).
Examples of indicators that can be produced from these data sources include: the number and type
of vaccine doses given at a primary care centre; the number of bed nets distributed in a community;
the number of nurses working in hospitals or public health units; the total budget of an institution
and breakdown by spending categories; the total and average number of patients served in a day,
month or year; and the number of surgical procedures performed in a hospital.
Several of the input, process and output indicators proposed in the monitoring framework may
be obtained from resource and service records, including health worker density and distribution,
hospital bed density, service utilization and bed occupancy rate.
Individual records
Individual records include medical and non-medical information for those who have had contact
with, or are waiting for, health-care services. Typically recorded in medical charts, this information
may become part of the patient-level database of an institution. In many high-income countries,
data on hospital inpatient and emergency care are categorized according to the International
Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) and the
International Classification of Health Interventions.
These databases allow summary and analysis of reasons for admission or consultation and of the
diagnostic and therapeutic interventions carried out. High-priority programmes such as those
targeting malaria, HIV and tuberculosis are often delivered through health facilities, so programme-
and patient-level data for these conditions are also available in institutional databases. Some
institutions retain the historical medical information of individual patients, along with demographic
characteristics such as age (date of birth), sex/gender, marital status, race/ethnicity, education,
occupation and place of residence.
Several indicators in the SDG and UHC Regional Monitoring Framework can be derived from
individual health records. Examples include hospital admission and readmission rates, 30-day in-
hospital mortality rate for acute myocardial infarction, postoperative sepsis, average length of stay,
treatment of confirmed malaria cases, HIV viral load suppression, and institutional mortality rates
for selected medical conditions.
Payment and insurance-based records

Payment and insurance-based records may contain detailed information on patients and the
services they have received. In a typical fee-for-service scheme, for example, providers send a
record for every service rendered to the corresponding payer. Payers may include governmental
and nongovernmental organizations, and private health insurance organizations.
In a fee-for-service scheme, where payment is made on the basis of complete and accurate records,
there may be some information not available at other sites. For example, insurance organizations
may keep detailed records of diagnostic tests and procedures performed for individual patients.
This information can be used for some of the indicators in the monitoring framework, such as
those for cervical cancer screening and duplicate medical tests. Drug payment plans keep detailed
31
information on medications prescribed. If a medication is prescribed for specific medical conditions,

this information can be used to support estimates of the prevalence of these conditions.
Payment and insurance-based records can help to validate data on indicators coming from other
institution-based sources. For example, data on the number of immunizations delivered in a
community, obtained from service or individual records, may be compared with data from payment
records if the programme is delivered under a fee-for-service format.
One limiting characteristic of institution-based data is that by definition it only covers people who
have interacted with the institution or service. In monitoring inequity, populations with limited
institutional access are often of high interest. Therefore, institution-based data may not be helpful
in monitoring equity, unless the social and economic characteristics of the service users can be
compared with those of the general catchment population. This means that estimates of the
denominator – all people who need services – must be derived from other sources.
It is important to continuously monitor and improve institution- or facility-based systems of

recording, reporting and compiling statistics, as they are valuable data sources complementary
to population-based census and survey data. Administrators at different levels of the system need
clear guidance and support on the requirements for maintenance of the systems (that is, concepts,
definitions, classifications, timeliness, etc.).
Countries should make the effort to reduce fragmentation and improve standardization of
administrative data at the country level. Despite some problems, administrative data may be
essential for monitoring inequity at lower administrative levels such as districts or municipalities.
The detail available in such data is not usually found in other data sources. In fact, at the local level,
administrative data may be the only source of health information.42
Surveillance
Surveillance is the continuous analysis, interpretation and feedback of systematically collected

data, generally using methods selected for their practicality, uniformity and rapidity rather than
for detailed accuracy or completeness.43 By observing trends over time, related to place and
persons, changes can be observed or anticipated and appropriate action can be taken, including
investigative or control measures. Sources of data may relate directly to disease conditions or to
factors influencing disease. Thus, they may include:44
a. mortality and morbidity reports based on death certificates, hospital records, general practice
sentinels, or notifications;
b. laboratory diagnoses;
c. outbreak reports;
d. vaccine utilization-uptake and side effects;
e. sickness absence records;
f. disease determinants such as biological changes in agents, vectors, or reservoirs; and
g. susceptibility to disease, as by skin testing or serological surveillance (for example, serum banks).
42
43
Last JM, editor. A dictionary of epidemiology. Third edition. New York: Oxford University Press; 1995.
44
Ibid.
32
There are multiple types of surveillance systems. Examples include outbreak and disease surveillance,
sentinel surveillance, risk factor surveillance and demographic surveillance.45
Outbreak and disease surveillance

Outbreak and disease surveillance systems are designed to track cases of epidemic-prone diseases
as well as their risk factors. Frequent reporting by health facilities, including laboratories, is the main
source of data, but other sources are also used, such as media reports.
Sentinel surveillance
In sentinel surveillance systems, a sample of clinics is used for intensive monitoring of specific
disease-control programmes, such as those for HIV and malaria. These selected sites (such as a few
primary care centres) provide timely information representative of the broader clinic system dealing
with that condition.
Risk factor surveillance

Risk factor surveillance is the gathering and monitoring of data for factors linked to the propensity
for NCDs in a community. These data are most often obtained through regular surveys either of
particular groups or of the general population.
Demographic surveillance
There are demographic surveillance sites in many low- and middle-income countries. They maintain
a longitudinal birth and death registration system for a defined local population and often collect
data on maternal and child health, cause of death, and other health-related issues relevant to the
community.
Data from surveillance systems can provide detailed information on a single condition or from
selected sites. The data can help to correct over- or under-reporting of diseases or conditions from
other sources. However, surveillance data may not be representative of the whole population and
reporting practices vary from country to country. This challenges comparability in global disease
surveillance, as information on the same disease is collected in a somewhat different way in different
countries.
Some of these challenges can be addressed by integrating surveillance data into larger health
information systems. For example, many countries use District Health Information Software (DHIS),
an open-source health management information platform, to monitor health interventions, improve
surveillance and speed up data access. For health organizations and governments, DHIS can help
manage operations, monitor health processes and services, and improve communication.
45
33
5.2 Metadata and tracer indicators

Metadata
Metadata refer to the detailed information that is necessary to understand every aspect of indicator
development, analysis and interpretation. Metadata are typically presented as a template with
standardized attributes (for example, indicator numerator and denominator, data sources and
method of estimation). Indicator metadata are available from the WHO Global Reference List of
100 Core Health Indicators,46 and from the UN Statistical Commission’s Inter-Agency and Expert
Group on SDG Indicators (IAEG-SDG).47 Volume 2 of this report presents the metadata for all 88
indicators that have so far been included in the SDG and UHC Regional Monitoring Framework.
Key indicator metadata comprise: the indicator definition, including numerator and denominator;
and disaggregation, including equity stratifiers, data sources, method of estimation and other
associated attributes of nationally reported health-related statistics and global estimates.
Metadata give users a better understanding of available data, promote the proper interpretation
and use of information for exploring health situations and trends, and facilitate standardization
and harmonization of indicators collected by different agencies in various countries. To illustrate
the information available in metadata, Table 4 presents some data elements and attributes
available for the indicator “births attended by skilled health personnel”. For countries, the use of
metadata has the following benefits:
Table 4. Key metadata for SDG 3 Indicator 3.1.2 proportion of births attended by skilled health
personnel
Field Information
Indicator name Births attended by skilled health personnel (%).
Definition Percentage of live births attended by skilled health personnel during a specified time period.
Numerator Number of births attended by skilled health personnel (doctors, nurses or midwives) trained in
providing life-saving obstetric care, including giving the necessary supervision, care and advice to
women during pregnancy, childbirth and the postpartum period, to conduct deliveries on their own,
and to care for newborns.
Denominator The total number of live births in the same period.
Disaggregation Age, parity, place of residence, socioeconomic status, type of provider.
Method of estimation Data for global monitoring are reported by the United Nations Children’s Fund (UNICEF) and WHO. These
agencies obtain the data – both survey and registry data – from national sources. Before data can be
included in the global databases, UNICEF and WHO undertake a process of data verification that includes
correspondence with field offices to clarify any questions.
In terms of survey data, some survey reports may present a total percentage of births attended by a
type of provider that does not conform to the MDG definition (e.g. total includes providers who are
not considered skilled, such as community health workers). In this case, the percentage delivered by a
physician, nurse or midwife are totaled and entered into the global database as the MDG estimate.
Predominant type of statistics: adjusted.
Preferred data sources Household surveys
Source: Inter-agency and Expert Group on SDG Indicators (IAEG-SDG). Compilation of metadata for the proposed global indicators for the review of the 2030 Agenda
for Sustainable Development. New York: United Nations; 2016.
46
Global Reference List of 100 core health indicators, 2015. Geneva: World Health Organization; 2015 (http://www.who.int/healthinfo/
indicators/2015/en/; accessed 21 August 2017).
47
Inter-agency and Expert Group on SDG Indicators (IAEG-SDG). Compilation of metadata for the proposed global indicators for the review of
the 2030 Agenda for Sustainable Development. New York: United Nations; 2016 (http://unstats.un.org/sdgs/iaeg-sdgs/metadata-compilation/;
34
For countries, the use of metadata has the following benefits:

reduces excessive and duplicative reporting requirements
serves as a general reference and guidance for standard indicators and definitions
enhances efficiency of investment in data collection
enhances availability and quality of data on results
improves transparency and accountability.
Tracer Indicators
A tracer indicator is a methodologically identified indicator that can provide a good picture of
several aspects of the health-care system. For example, the hospital readmission rate may be used
to trace or monitor the overall quality of care provided in hospitals, and also reflect to some extent
access to and quality of primary care. The United States publication Healthy People 2020 offers a good
example of the use of tracer indicators. It provides a comprehensive set of 10-year national goals
and objectives for improving the health of all Americans.48 The document contains 42 topic areas
that together reflect more than 1200 objectives. A small set of indicators, however, called leading
health indicators (LHIs), is used to assess the status of high-priority health issues and actions that
can be taken to address them. For example, two LHIs are used to measure progress towards access
to health services: the percentage of persons with medical insurance and the percentage of persons
with a usual primary care provider.
For SDG 3, Indicator 3.8.1 specifically targets coverage of essential health services. This indicator is
defined as the average coverage of essential services based on tracer interventions for reproductive,
maternal, newborn and child health; infectious disease; NCD; and service capacity and access,
among the general and also the most disadvantaged population.
Following the SDG Indicator 3.8.1 definition, WHO has identified 16 tracer indicators and proposed a
methodology to combine them into one index.49 The index provides an overall picture of essential
health service coverage in a country.
The methodology proposed by WHO is expected to evolve over time to capture inequality in service
coverage, to improve the relevance of the index to higher-income countries and to incorporate
feedback from various stakeholders. Additional technical information, including index calculation
and data availability, can be found in the technical note Developing an Index for the Coverage of
Essential Health Services.50 All 16 current tracer indicators are presented in Box 5, and their metadata
are available in Appendix 5 of this report.
All 16 tracer indicators are combined into a single index for coverage of essential health services
as defined in the SDG Indicator 3.8.1. The indicators were identified under the principle of effective
coverage, that is, they should capture the extent to which people in need of health services
receive quality (effective) care. The definition includes four categories of tracer interventions:
reproductive, maternal, newborn and child health; infectious disease; NCD; and service capacity
and access.
48
Leading health indicators. In: HealthyPeople.gov [website]. Washington, DC: Office of Disease Prevention and Health Promotion; 2017 (https://
www.healthypeople.gov/2020/Leading-Health-Indicators; accessed 22 August 2017).
49
Hogan D, Hosseinpoor AR, Boerma T. (2016). Technical note. Developing an index for the coverage of essential health services. Geneva: World
Health Organization; 2016 (http://www.who.int/healthinfo/universal_health_coverage/UHC_WHS2016_TechnicalNote_May2016.pdf?ua=1;
50
Ibid.
35
For each tracer category, four tracer indicators are combined into a single index (see Box 5). Figure
10 presents the tracer indicators and interventions along with the construction of the UHC service
coverage index.
Tracer indicators for monitoring progress on health service coverage

Box 5 (estimated for the national population and, when available, for disadvantaged populations)
REPRODUCTIVE, MATERNAL, NEWBORN AND CHILD NONCOMMUNICABLE DISEASES

HEALTH • Prevalence of non-raised blood pressure (%)
• Demand for family planning satisfied with a modern • Mean fasting plasma glucose (mmol/L)
method among women aged 15–49 (%) • Cervical cancer screening among women aged 30–49
• Antenatal care – 4 or more visits (%) (%)
• 1-year-old children who have received three doses of a • Adults aged ≥15 years not smoking tobacco in last 30
vaccine containing diphtheria, tetanus and pertussis (%) days (%)
• Care-seeking behaviour for children with suspected
pneumonia (%) SERVICE CAPACITY (AND ACCESS)
• Hospital beds per capita (in relation to a minimum
INFECTIOUS DISEASES threshold)
• Tuberculosis cases detected and treated (%) • Health professionals per capita (in relation to a minimum
• People living with HIV receiving antiretroviral treatment threshold): physicians, psychiatrists and surgeons
(%) • Proportion of health facilities with basket of essential
• Population at risk sleeping under insecticide-treated bed medicines available
nets (%) • International Health Regulations (2005) core capacity
• Households with access to improved sanitation (%) index
Source: World health statistics 2017: monitoring health for the SDGs. Geneva: World Health Organization; 2017.
In Figure 10, the tracer indicator “immunization coverage” is based on children 1 year of age having
received three doses of a vaccine containing diphtheria, tetanus and pertussis (DTP3). This vaccine
often includes antigens against other conditions (such as hepatitis B and Haemophilus influenzae
type B); this means monitoring DTP3 coverage may be a reasonable proxy for assessing full child
immunization in a country. When combined with the other three tracer indicators, a tracer index
can be built and used to trace the coverage of essential health services for reproductive, maternal,
newborn and child health.
The four tracer indices in Figure 10 can then be combined to reflect the overall national coverage of
essential health services. This composite index will help measure progress toward UHC (SDG Target 3.8).
36
Figure 10. Calculation of UHC service coverage index
Tracer Intervention 1:
Reproductive, maternal, newborn and
child health
Tracer indicators • Family planning

• Pregnancy and delivery care
• Child immunization Tracer Index 1
• Child treatment
Tracer Intervention 2:
Infectious diseases
• Tracer indicators… Tracer Index 2
UHC Service
Tracer Intervention 3: Coverage Index
Noncommunicable disease

It traces national
coverage of
Tracer Intervention 4: essential health
Service capacity and access services
Equity-adjusted UHC
coverage index
Source: Hogan D, Hosseinpoor AR, Boerma T. (2016). Technical note. Developing an index for the coverage of essential health services. Geneva: World Health
Organization; 2016 (http://www.who.int/healthinfo/universal_health_coverage/UHC_WHS2016_TechnicalNote_May2016.pdf?ua=1; accessed 22 August 2017).
5.3 Data availability and existing methodologies

Availability of timely, quality data is fundamental to measurement of progress towards SDGs
and UHC and for guiding resource allocation. However, data may be lacking for many indicators,
especially in low- and middle-income countries.51 Statistical modelling is frequently used to produce
health statistics that are comparable across countries.52 However, efforts are still needed to improve
estimates, address data gaps, set common standards for documentation, share data and methods,
and ensure regular interaction and collaboration among all groups involved.53
Although improvement is needed in the comparability of data, there are established methodologies
and standards available for approximately 87% of the health and health-related SDG indicators.
Table 5 classifies these indicators into tiers, agreed by the IAEG-SDG.54 Twenty-two of the 47 SDG
indicators are classified as Tier I, which means data are regularly produced by countries. For 19
indicators (Tier II), data are not regularly produced and for the remaining six indicators (Tier III) data
51
Boerma T, Mathers CD. The World Health Organization and global health estimates: improving collaboration and capacity. BMC Medicine.
2015;13:50. doi: 10.1186/s12916-015-0286-7.
52
Ibid.
53
Ibid.
54
Inter-agency and Expert Group on SDG Indicators (IAEG-SDG). Tier classification for global SDG indicators. New York: United Nations; 2017
(https://unstats.un.org/sdgs/iaeg-sdgs/tier-classification/; accessed 22 August 2017).
37
Table 5. Classification of health and health-related SDG indicators (as of 20 April 2017)
# of health SDG # of health-related SDG

Tier Definition Total
indicators indicators
Tier I Indicator conceptually clear
Established methodology and standards available 13 9 22
Data regularly produced by countries
Tier II Indicator conceptually clear
Established methodology and standards available 10 9 19
Data are not regularly produced by countries
Tier III Indicator for which there is no established methodology
4 2 6
Standards or methodology are being developed/tested
Total 27 20 47
Source: WHO Source: Inter-agency and Expert Group on SDG Indicators (IAEG-SDG). Tier classification for global SDG indicators. New York: United Nations; 2017 (https://
unstats.un.org/sdgs/iaeg-sdgs/tier-classification/ accessed 22 August 2017).
are not available. Data are regularly collected for about 50% of the additional indicators to monitor
UHC, as listed in Appendix 2.
The SDG health indicators in Tier III (not available) include coverage of treatment interventions
for substance use disorders (3.5.1), coverage of essential health services (3.8.1), proportion of the
target population immunized with all vaccines included in the national programme (3.b.1), and
the proportion of health facilities that have a core set of relevant essential medicines available and
affordable on a sustainable basis (3.b.3).
Data for the health and health-related SDG indicators and for the additional indicators to monitor
UHC may be collected from routine administrative systems and programme collection on an annual
or biennial basis, or through regular survey. The latter may include census or special household
surveys, which may only be updated every three to five years, depending on survey cycles.
For the irregularly produced indicators, data are currently collected intermittently through specific-
purpose survey collection, observatory data, the criminal justice system, and/or public health and
civil registration. A systematic strategy is needed for data collection for these indicators as data for
most of the health-related SDG indicators are held outside the health sector. A few of these will also
require methodological work to ensure comparability.
38
6. MOVING FORWARD
This chapter examines some of the challenges to be addressed to ensure effective monitoring of
progress towards SDGs and UHC, including those involved with data collection and gaps and those
related to the strengthening of HIS and health information capacities. The chapter also discusses
short- and long-term solutions and opportunities to address these challenges.
6.1 Challenges
Common regional challenges to data collection for SDG and UHC monitoring include the limited
availability of data, insufficient disaggregation of data, and poor data quality and reliability. Factors
limiting the strengthening of HIS include the use of fragmented and independent information
systems, limited use of information standards and exchange mechanisms, poor information
infrastructure and tools, and limited capacity to generate knowledge for decision-making. Meeting
these challenges will require improvements in governance, commitment and leadership; short- and
long-term investment in health information infrastructure and human resources; and innovative
approaches to the use of existing data sources.
Table 6 classifies these challenges into seven categories and maps the potential solutions and
opportunities that can help address them. The check marks indicate the solutions and opportunities
with the greatest potential impact. Countries are encouraged to use this information to guide policy
dialogue on interventions that might address their own information-related challenges and be
included in action plans.
The most common gaps in data sources for monitoring SDGs and UHC relate to health service
coverage and financial protection, disaggregation to expose coverage inequities, and the
effectiveness of coverage. This last includes information on whether people receive the services
they need, as well as the quality of services provided and the ultimate impact on health.55
For some SDG indicators, there are no data or the data are not collected regularly, and for others
there is no established methodology or the methodologies are still being developed. Given the
current uncertain comparability of country data and the importance of improving cross-country
comparability, countries are expected to use the established indicator metadata to support data
collection and reporting.
In general, a large amount of data used to inform health indicators is drawn from global estimates.
Although these estimates may enhance cross-country comparisons, they may differ from official
statistics prepared and endorsed by the countries. Global estimates have large confidence intervals,
especially for countries with weak HIS and where the quality of underlying empirical data is limited.
Disaggregated data are not available for all indicators and stratifiers. Currently, the best disaggregated
data are for reproductive, maternal and child health, which are drawn from surveys. For other health
55
Tracking universal health coverage: first global monitoring report. Joint WHO/World Bank group report. Geneva: World Health Organization
and World Bank; 2015 (http://www.who.int/healthinfo/universal_health_coverage/report/2015/en/; accessed 22 August 2017); Murray CJL. The
Data for Health initiative: improving availability and quality of health data. In: Healthdata.org [website]. Seattle: Institute for Health Metrics
and Evaluation; 2017 (http://www.healthdata.org/acting-data/data-health-initiative-improving-availability-and-quality-health-data; accessed
22 August 2017).
39
targets, disaggregation varies significantly. Disaggregation within countries can reveal important
health differences across population groups. Without disaggregation, national-level reporting will
mask these differences.
Table 6. Challenges and opportunities to effectively monitor progress towards achieving the SDG
and UHC
Challenges to SDG and UHC monitoring
Limited
Limited use of Poor
Limited Silos / capacity to
Solution/opportunity Insufficient Poor data information information
data fragmented generate
disaggregated quality and standards infrastruc-
availa- information knowledge
data reliability and exchange ture and
bility systems for decision-
mechanisms tools
making
Short-term solution:
Strengthen capacity of statistical
offices at all levels
3 3 3 3
Promote the use of metadata and
international standardized indicators
3 3 3
Develop multisectoral, coordinated,
and standardized data collection and 3 3 3 3 3
reporting strategies
Catalogue data sources available at
national, provincial and district levels
3 3
Harmonize data collection through
surveys and health facility reporting 3 3 3 3
systems
Promote the use of national health
accounts (NHAs)
3 3
Promote the use of international and
national information classifications 3 3 3
and standards (e.g. postcodes)
Adopt electronic data collection and
storage methods
3 3 3 3 3
Strengthen health information
literacy of health-care providers and 3 3 3 3
managers
Adopt electronic health records (EHRs) 3 3 3 3 3 3 3
Qualitative monitoring 3 3
Medium- and long-term opportunity:
Big data 3 3 3 3 3 3 3
Geospatial data and technologies 3 3 3 3
Sources of information from other
sectors
3 3 3 3
For most indicators, effective population-based surveys may be the key to improving the picture of
health service and financial protection coverage. For example, two main indicators on catastrophic
and impoverishing health expenditure depend on household expenditure data, typically obtained
through household surveys. However, household surveys do present some shortcomings, including
lack of standardization across countries regarding the recall period used and the survey years. China
uses national health service surveys, whereas Cambodia, the Lao People’s Democratic Republic,
Mongolia, the Philippines and Viet Nam use socioeconomic surveys or income and expenditure
surveys. Efforts are needed to standardize survey instruments and methods of implementation.
40
MOVING FORWARD
Many countries face difficulties in measuring health service needs, especially in settings where a
large proportion of the population may not seek services and whose health issues therefore remain
invisible. Most of these indicators require data from population-based surveys. Data blind spots on
key public health concerns such as NCDs have also been identified, particularly in low- and middle-
income countries. Registration is often weak, disease registries are suboptimal, and risk factor
surveys are sporadic.56
Other challenges include fragmented information systems, limited use of standards and poor
information infrastructure. These should be addressed through preparing an action plan to prioritize
the implementation of interventions in a sequentially coordinated manner. For example, countries
should ensure that good infrastructure and information tools are in place before other challenges
such as limited data availability and limited use of information standards are tackled.
The major challenge of fragmented information systems is faced by many countries. This
fragmentation leads to ineffective and inefficient use of health data and information. Many health
systems produce large, and sometimes unnecessary, volumes of health data that may be duplicated,
and may be difficult to combine in ways to support progress reviews and decision-making. Efforts to
produce unfragmented and coordinated health and health-related information systems at all levels
are paramount, including linkages with social information systems.
Generally, the Region has limited capacity to generate knowledge for decision-making, particularly
in low- and middle-income countries. Challenges in the health workforce include limited ability to
use information to fill knowledge gaps and inform decision-making, identify relevant knowledge
gaps and commission needed research, to link research, policy and action, and to make use of
foresight methodologies and trend analysis to strengthen planning. A strong national HIS requires
health-care providers, managers, decision-makers and policy-makers with strong health information
literacy.
6.2 Short-term opportunities and solutions

Some short-term opportunities and solutions to support effective monitoring of SDGs and UHC
are outlined in Table 7. This section describes them through four main categories or applications:
strengthening HIS and health information capacities, subnational geographical analysis, electronic
health records and data linkages, and development of new indicators.
Strengthening HIS and health information capacities
Strong national HIS are critical to effective monitoring of SDG and UHC progress. Well-managed
HIS supports decision-making, accountability and the coordination of health investments made by
governments and other stakeholders, including donors. Country leadership is essential to building a
strong HIS. Table 7 outlines some key guiding components of a well-functioning national HIS; these
can assist countries to shift focus and attention to more strategic areas by providing a foundation
for discussion and a framework for action.
An active national coordinating body (for example, the National Statistics Office) with strong
oversight and control, working with multiple agencies and sectors, is central to developing a strong
HIS. The human, technical and financial capacities of this body should be strengthened to meet the
56
Noncommunicable diseases in the Western Pacific Region: a profile. Manila: WHO Regional Office for the Western Pacific; 2012 (http://www.
wpro.who.int/noncommunicable_diseases/documents/ncd_in_the_wpr.pdf?ua=1; accessed 22 August 2017).
41
Table 7. Key components of a strong national health information system (HIS)
Component Best practice
Governance An active national coordinating body (e.g. National Statistics Office) provides oversight, control and
support for the multiple agencies and sectors involved.
Ministry of Health provides leadership, coordination and both broad and specific incentives for data
sharing and use through institutionalized arrangements.
Information use and Reliable and good-quality data and information are compiled and increasingly shared and used in
transparency policy- and decision-making.
Different levels of data and data disaggregation are available.
Infrastructure There is coordinated, government-led direct and indirect incentive-based investment in fundamental
information infrastructure and tools.
Coordinated health and health-related data and information systems are available at all levels.
Fragmented data collection is gradually eliminated.
Human capital There is strong health information literacy among health-care providers, managers, decision-makers
development and policy-makers.
System and data Strong and harmonized data collection systems have clear information flows and data processes.
interoperability International and national information classifications and standards are adopted.
Source: Adapted from the HIS Country Ownership and Leadership Continuum developed by WHO, USAID and ITU (http://www.who.int/ehealth/resources/his_
continuum.pdf?ua=1; accessed 21 August 2017).
country’s needs for data collection, disaggregated data and analysis. This body could, for example,
streamline and centralize the management of human resources in statistics within line ministries.
The Ministry of Health would provide continuous leadership and coordination and both broad
and specific incentives for data-sharing and use. The Ministry of Health may also lead coordinated
government-led direct and indirect incentive-based investments in basic information infrastructure
and tools. The availability of reliable, good-quality data and information will enable priority-setting
and informed decision-making, and will promote accountability of various stakeholders.57
To ensure indicators are consistent, valid and comparable, each country must use globally agreed
indicator definitions and global measurement methods, and promote the use of internationally and
nationally standardized information classification systems and standards (such as the ICD-10). Given
the nature of SDGs, indicators that are cross-cutting and multisectoral also require coordinated
strategies to support standardized data collection and reporting.
It may be useful for each country to catalogue and describe the data sources available at national,
province, district or other administrative levels determine which sources can be used for SDG, UHC
and equity monitoring. Mapping of these data sources against the indicators in the monitoring
framework would also help identify important gaps where additional information system capacity
is required to support reporting of health indicators and related equity stratifiers.
For many countries, household surveys are a key source of information as they can provide accurate
population statistics for a number of indicators. These statistics can be further disaggregated by
socioeconomic status, place of residence, sex and other relevant stratifiers. Health facility data,
including stratifying data, are a valuable data source for several indicators in some countries.
57
Kindornay S, Bhattacharya D, Higgins K. Implementing Agenda 2030: unpacking the data revolution at country level. Dhaka: Centre for
Policy Dialogue; 2016 (http://www.post2015datatest.com/wp-content/uploads/2016/07/Implementing-Agenda-2030-Unpacking-the-Data-
Revolution-at-Country-Level.pdf; accessed 22 August 2017).
42
MOVING FORWARD
Strengthening and harmonizing currently fragmented data collections from surveys and health
facility reporting systems will be critical for the effective monitoring of the SDGs and UHC.
The use of national health accounts (NHAs) should also be encouraged. Overall, governments have
limited information on financial flows and the generation of human and material resources. NHAs
can provide essential information to monitor the ratio of capital to recurrent expenditure, or of any
one input to the total, and to observe trends. NHAs capture foreign as well as domestic, public
and private inputs, and usefully assemble data on physical quantities – such as the numbers of
nurses, items of medical equipment, district hospitals – as well as their costs. There are now NHAs
in some form for most countries, but they are often rudimentary and not yet widely used as tools of
stewardship. NHA data may help the Ministry of Health to think critically about input purchases by
all fund-holders in the health system.
It may prove useful to commission specific studies to build monitoring capacity in support of best
practices on information use. For example, the Philippines is conducting a 15-year longitudinal cohort
study on adolescents to track the changes they go through, the opportunities and challenges they
face, and the kinds of choices they make. Information on their profiles, characteristics, vulnerabilities
and needs will be collected through household and community surveys, focus group discussions
and case studies. The purpose of this study is to put a human face to the 2030 Agenda for Sustainable
Development and to inform policy-making and programming on health, education and other key
areas for today’s and tomorrow’s young people.
Subnational geographic analysis
Geographic analysis is key to understanding how health service coverage develops, from simply
plotting health facilities on a map to show availability to simultaneous analysis of multiple layers
of data to demonstrate UHC effectiveness. It is an essential part of gathering disaggregated data to
expose hidden gaps in service provision and to promote UHC.
Stratifying data at the level of subnational geographic areas, such as provinces, states or districts, can
complement the analysis of data at the individual or household level. For within-country monitoring,
dimensions unavailable in one data source may be captured from other sources. Subnational
areas are often aligned with administrative districts, which facilitates the use of administrative-
level data.58 For example, the distribution of health system inputs and outputs such as service
delivery can be compared to the determinants of health – poverty, education and/or employment.
Since interventions to reduce inequities are likely to be implemented at the administrative level,
subnational monitoring of health inequities may be useful for benchmarking, with implications for
resource allocation, planning and evaluation.59
Actions to increase the quality and availability of area-based data include standardizing data
collection by health facilities, and adoption of electronic data collection and storage methods.
Common systems of small-area coding can be applied across data sources, such as censuses, CRVS,
surveys and facility data; this permits linkages among different sources. By increasing the use of
area-based units for analysis, including greater integration of data from other reliable sources
(vital registration, censuses and administrative data), the monitoring of health inequities may be
strengthened and expanded across a range of health topics.
58
Hosseinpoor AR, Bergen N. Area-based units of analysis for strengthening health inequality monitoring. Bull World Health Organ.
2016;94(1):856–8. DOI: 10.2471/BLT.15.165266.
59
Bauze AE, Tran LN, Nguyen KH, Firth S, Jimenez-Soto E, Dwyer-Lindgren L, et al. Equity and geography: the case of child mortality in Papua New
Guinea. PloS One. 2012;7(5):e37861. doi: 10.1371/journal.pone.0037861.
43
Electronic health records and data linkages
Countries in the Region are increasingly adopting digitization of data and electronic health records
(EHRs), in response to mandatory requirements and efforts to improve the quality of health care and
reduce costs.
EHR data are input by providers in the process of providing care. Health-care statistics are derived
from EHR data warehouses. However, the data requirements for health statistics differ from those
for patient care. Using data designed for patient care to track indicators for development and policy-
making requires that countries develop strong privacy and confidentiality frameworks.
An important challenge may be interoperability. EHRs store data in a variety of standardized

domains (such as the ICD-10), but the frequent use of local enhancements to the code sets prevents
full interoperability among EHR systems. Efficient linking and anonymizing of EHRs will be crucial
to exploitation of these data for the benefit of patients and public health. It will also be critical to
develop a framework and methods for data linkages.60
Development of new indicators
There are some areas in the framework where indicators have not been proposed. This may be
because data are not currently collected or because further work is needed to develop or select an
appropriate indicator. Over the next two years, additional indicators may be explored using existing
data sources. The focus areas for future indicator development are outlined in Table 8. They have
been mapped to the framework and indicator domains of the SDG and UHC Regional Monitoring
Framework as presented in this report. Additional details can be found in Appendix 6.
Table 8. Focus areas for future indicator development mapped to the SDG and UHC Regional
Monitoring Framework
Monitoring domain / indicator domain Focus area
Health Impact Through the Life Course:
• Healthy life expectancy
Life expectancy and well-being
• Subjective well-being
• Mental health care
Mortality
• Palliative care
Universal Health Coverage:
• Hepatitis treatment care
Heath service coverage
• Mental health care
Health System Resources and Capacity:
Effectiveness • Disability-specific and community-based rehabilitation
• Disability-specific and community-based rehabilitation
Quality and safety • Health system performance
• Quality in long-term care
Efficiency and sustainability • Health system performance
• Information and communication technologies
Resources and infrastructure • Mental health care
• Violence and injury prevention
60
OECD. Strengthening health information infrastructure for health care quality governance: good practices, new opportunities and data
privacy protection challenges. Paris: Organisation for Economic Co-operation and Development; 2013 (http://www.oecd.org/publications/
strengthening-health-information-infrastructure-for-health-care-quality-governance-9789264193505-en.htm; accessed 22 August 2017).
44
MOVING FORWARD
For example, mental health care requires the development of indicators in the areas of mortality,
health service coverage, and resources and infrastructure. Country HIS do not routinely collect
data on a core set of mental health indicators and cannot provide reliable information on service
coverage. While the need for surveillance of specific disorders may vary from country to country,
basic data gathering is needed in all countries.61 The complete recording of suicide deaths in death-
registration systems requires good linkages with coronial and police systems as the process is often
disrupted by stigma and delays in determining the cause of death.
6.3 Opportunities in the medium and long term

A number of innovative approaches have the potential to enhance current information use and the
production of official statistics and indicators. These approaches involve big data, geospatial data
and technologies, and data from sources beyond the health sector.
The potential value of big data in health care lies in combining traditional and new forms of data
at both the individual and population levels.62 Big data approaches may be able to manage the
increased quantity of data that need to be generated to support SDG monitoring, including equity
analyses.
Geospatial analysis is the application of statistical and other analytic techniques to geographic
data. This information can describe where people are and their spatial relationship to each other;
this in turn can help governments plan service coverage improvements and measure and monitor
outputs and outcomes. Information from other sectors and from some commercial datasets can
complement data already collected within the health sector.
Appendix 7 describes in more detail these innovative approaches, including their relationships with
SDG and UHC monitoring. Box 6 presents examples of countries using geographic information
systems (GIS) to support health service coverage, and Box 7 outlines the benefits of using big data
in the Korean National Health Insurance System.
Box 6 Country examples of GIS use to support health service coverage
Philippines:
In the context of prenatal, delivery and postpartum services, GIS has been used for design of household surveys to ensure a
geographically based sample of health facilities and households.
Cambodia and Lao People’s Democratic Republic:
These two countries have used GIS in the context of emergency obstetric care services for spatial analysis and modelling to measure
physical accessibility and geographic coverage at the subnational level and to provide scaling-up scenarios towards UHC.
China, Republic of Korea, Lao People’s Democratic Republic, Solomon Islands and Vanuatu:
In the context of malaria control and elimination, these countries have used GIS for spatial analysis, for the modelling of the spatial
distribution of malaria risk and to support decision-making.
Source: Roth S, Landry M, Ebener S, Marcelo A, Kijsanayotin B, Parry J. The geography of universal health coverage. Why geographic information systems are
needed to ensure equitable access to quality health care. ADB Briefs No. 55. Manila: Asian Development Bank and World Health Organization; 2016.
61
Regional agenda for implementing the Mental Health Action Plan 2013–2020 in the Western Pacific. Towards a social movement for
action on mental health and well-being. Manila: WHO Regional Office for the Western Pacific; 2015 (http://iris.wpro.who.int/bitstream/
handle/10665.1/10893/9789290617020_eng.pdf; accessed 22 August 2017).
62
Wyber R, Vaillancourt S, Perry W, Mannava P, Folarnmi T, Celi LA. Big data in global health: improving health in low- and middle-income
countries. Bull World Health Organ. 2015;93(3):203–8. doi: 10.2471/BLT.14.139022.
45
Box 7 Big Data and the Korean National Health Insurance System
The Republic of Korea’s National Health Insurance Service (NHIS) is the nonprofit single insurer for everyone in the country. In
providing health and long-term insurance, reimbursing fees to institutions and conducting health screening for all, a large body
of computerized longitudinal data has become available in the NHIS on various health dimensions, including pathophysiological
status, health behaviour, health conditions, and service use and fees. The data are representative of everyone in the country.
The NHIS has set up the National Health Information Database (NHID), which integrates these data through individual identification
linkages. Analyses of these big data, such as the following, have produced evidence to inform public health policy:
• Identifying causality and predicting risk by linking health-screening data with medical history and socioeconomic
status.
• Creating an evidence base on health risk and disease by region and workplace to develop customized services in
communities and workplaces.
• Developing an accurate health–disease index and surveillance system to target chronic diseases, based on information
on use of services by chronic disease patients.
The data are being used to address pressing health issues, including the low birth rate, an ageing population and the chronic
diseases burden. Future plans include integrating the NHID with other public health data (for example, electronic medical records)
and climate, pollution and spatial network data.
Source: Regional Action Agenda on Achieving the Sustainable Development Goals in the Western Pacific. WHO Regional Office for the Western Pacific Region;
2017.
46
APPENDICES
Appendix 1. Monitoring framework for SDGs and UHC in the Western Pacific
Health impact through the life course – How healthy are people in the Western Pacific?
Is it the same for everyone at all stages of life?
INDIVIDUAL HEALTH
• Low birth weight • Adolescent births • HIV incidence
• Neonatal • Maternal • TB incidence
mortality mortality • Malaria
incidence
• Under-5 mortality • Intimate partner violence • Hepatitis B incidence
• Malnutrition among children <5
• NCD mortality
• Stunting among children <5
POPULATION HEALTH
• Life expectancy at birth • Mortality attributed to household • People requiring interventions
• Intentional homicide deaths and ambient air pollution (preventive chemotherapy) against
• Unintentional poisoning mortality • Mortality attributed to unsafe water, neglected tropical diseases
• Conflict-related deaths unsafe sanitation and lack of hygiene • Need for family planning satisfied
• Use of assistive devices among with modern methods
people
Determinants of health – Are these factors contributing to good health? Where and for
whom are these factors changing? Is it the same for everyone?
ENVIRONMENTAL FACTORS • Annual mean levels of fine SOCIOECONOMIC FACTORS women, who have achieved
particulate matter in cities literacy and numeracy*
• % of population using safely • Clean household energy* • Unemployment rate*
managed sanitation services • Proportion of population
• % of population using safely HEALTH BEHAVIOURS living in poverty* PERSON-RELATED FACTORS
managed drinking-water • Harmful use of alcohol • Proportion of youth and • Overweight and obesity
services • Current tobacco use adults, both men and
Universal health coverage – Are all people accessing needed services

without suffering financial hardship?
FINANCIAL PROTECTION HEALTH SERVICE COVERAGE AND ACCESSIBILITY
• % of population protected against catastrophic/impoverishing • Coverage of essential health services
out-of-pocket expenditure • Access to affordable medicines and vaccines on sustainable basis
• % of population covered by social protection floors/systems
Health system resources and capacity – Does the system deliver value for money and is it sustainable?
What is the level of quality of care across the range of patient care needs?
EFFECTIVENESS • Postoperative sepsis as % of RESOURCES AND preparedness
all surgeries
• Immunization coverage for INFRASTRUCTURE HEALTH FINANCING
measles RESPONSIVENESS AND PEOPLE- • Health worker density and • Total current expenditure on
• Births attended by skilled CENTREDNESS distribution health as % of GDP
health personnel • Patient experience • Health facilities with
• Cervical cancer screening functioning water services
EFFICIENCY AND
• Laws and regulations that
SUSTAINABILITY
QUALITY AND SAFETY guarantee women access AVAILABILITY (AND READINESS) • Average length of stay
• 30-day hospital case fatality to sexual and reproductive • International Health
rate acute myocardial health Regulations (2005) capacity
infarction and health emergency
Note: Framework agreed to at the sixty-seventh session of the Regional Committee of the Western Pacific in October 2016.
* Not part of the proposed WHO collections, but included to illustrate the breadth of the monitoring framework.
48
APPENDICES
Appendix 2. WHO Western Pacific Region SDG and UHC indicator list
Table A. SDG 3 Indicators

Target SDG 3 (Ensure healthy lives and promote well-being for all at all ages) health indicators
3.1.1 Maternal mortality ratio
3.1.2 Proportion of births attended by skilled health personnel
3.2.1 Under-5 mortality rate
3.2.2 Neonatal mortality rate
3.3.1 Number of new HIV infections per 1000 uninfected population, by sex, age and key populations
3.3.2 Tuberculosis incidence per 100 000 population
3.3.3 Malaria incidence per 1000 population
3.3.4 Hepatitis B incidence per 100 000 population
3.3.5 Number of people requiring interventions against neglected tropical diseases
3.4.1 Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease
3.4.2 Suicide mortality rate
3.5.1 Coverage of treatment interventions (pharmacological, psychosocial, and rehabilitation and aftercare services) for
substance use disorders
3.5.2 Harmful use of alcohol, defined according to the national context as alcohol per capita consumption (aged 15 years and
older) within a calendar year in litres of pure alcohol
3.6.1 Death rate due to road traffic injuries
3.7.1 Proportion of women of reproductive age (aged 15–49 years) who have their need for family planning satisfied with
modern methods
3.7.2 Adolescent birth rate (aged 10–14 years; aged 15–19 years) per 1000 women in that age group
3.8.1 Coverage of essential health services (defined as the average coverage of essential services based on tracer
interventions that include reproductive, maternal, newborn and child health; infectious disease; noncommunicable
diseases; and service capacity and access, among the general and the most disadvantaged population)*
3.8.2 Proportion of population with large household expenditures on heath as a share of total household expenditure or
income
3.9.1 Mortality rate attributed to household and ambient air pollution
3.9.2 Mortality rate attributed to unsafe water, unsafe sanitation, and lack of hygiene (exposure to unsafe water, sanitation
and hygiene for all [WASH] services)
3.9.3 Mortality rate attributed to unintentional poisoning
3.a.1 Age-standardized prevalence of current tobacco use among persons aged 15 years and older
3.b.1 Proportion of the target population covered by all vaccines included in their national programme
3.b.2 Total net official development assistance to the medical research and basic health sectors
3.b.3 Proportion of health facilities that have a core set of relevant essential medicines available and affordable on a
sustainable basis
3.c.1 Health worker density and distribution
3.d.1 International Health Regulations (IHR) capacity and health emergency preparedness
* WHO has proposed an index with 16 tracer indicators for coverage of essential health services (Appendix 5). Twelve of these 16 indicators are in the core reference list
of 88 indicators in the monitoring framework (Appendix 2, Tables A, B and C). The remaining four are: (1) antenatal care – four or more visits (%); (2) tuberculosis cases
detected and treated (%); (3) population at risk sleeping under insecticide-treated bed nets (%); and (4) hospital beds per capita (in relation to a minimum threshold).
49
Table B. Other health-related SDG Indicators

Target Health indicators from other SDGs
1.a.2 Proportion of total government spending on essential services (education, health and social protection)
1.3.1 Proportion of population covered by social protection floors/systems, by sex, distinguishing children, unemployed
persons, older persons, persons with disabilities, pregnant women, newborns, work injury victims, and the poor
and the vulnerable
1.5.1 Number of deaths, missing persons and directly affected persons attributed to disasters per 100 000 population
11.5.1
13.1.1
2.2.1 Prevalence of stunting (height for age < –2 standard deviation from the median of WHO Child Growth Standards)
among children under 5 years of age
2.2.2 Prevalence of malnutrition (weight for height > +2 or < –2 standard deviation from median of the WHO Child
Growth Standards) among children under 5 years of age, by type (wasting and overweight)
5.2.1 Proportion of ever-partnered women and girls aged 15 years and older subjected to physical, sexual or
psychological violence by a current or former intimate partner in previous 12 months, by form of violence and by
age
5.2.2 Proportion of women and girls aged 15 years and older subjected to sexual violence by persons other than an
intimate partner in the previous 12 months, by age and place of occurrence
5.6.2 Number of countries with laws and regulations that guarantee full and equal access to women and men aged 15
years and older to sexual and reproductive health care, information and education
6.1.1 Proportion of population using safely managed drinking-water services
6.2.1 Proportion of population using safely managed sanitation services, including a handwashing facility with soap and
water
7.1.2 Proportion of population with primary reliance on clean fuels and technology
11.6.2 Annual mean levels of fine particulate matter (e.g. PM2.5 and PM10) in cities (population weighted)
16.1.1 Number of victims of intentional homicide per 100 000 population, by sex and age
16.1.2 Conflict-related deaths per 100 000 population, by sex, age and cause
16.1.3 Proportion of the population subjected to physical, psychological or sexual violence in the previous 12 months
16.2.1 Proportion of children aged 1–17 years who experienced any physical punishment and/or psychological aggression
by caregivers in the past month
16.2.2 Number of victims of human trafficking per 100 000 population, by sex, age and form of exploitation
16.2.3 Proportion of young women and men aged 18–29 years who experienced sexual violence by age 18
16.9.1 Proportion of children under 5 years of age whose births have been registered with a civil authority, by age
17.19.2(b) Proportion of countries that have achieved 100% birth registration and 80% death registration
50
APPENDICES
Table C. Additional Indicators to monitor UHC

Additional indicators to monitor UHC
Life expectancy at birth
Total current expenditure on health as percentage of gross domestic product
Seat belt-wearing rate
Motorcycle helmet-wearing rate
Bed occupancy rate
Immunization coverage rate for DTP3 (diphtheria-tetanus-pertussis)
Immunization coverage rate for measles
Stillbirth rate (per 1000 total births)
Case rate of congenital syphilis (per 100 000 live births)
Exclusive breastfeeding rate in infants 0–5 months of age
Incidence of low birth weight among newborns
Prevalence of anaemia in children aged 6–59 months
Anaemia prevalence in women of reproductive age (aged 15–49 years)
Age-standardized prevalence of raised blood glucose level among adults 18+ years
Age-standardized prevalence of overweight and obesity in persons aged 18+ years
Age-standardized prevalence of raised blood pressure among persons aged 18+ years
Age-standardized prevalence of insufficiently physically active persons aged 18+ years
Percentage of children under 5 years of age with suspected pneumonia who were taken to a health facility
Antiretroviral therapy (ART) coverage
Second-line treatment coverage among multidrug-resistant tuberculosis (MDR-TB) cases
Cervical cancer screening (rate)
Coverage of services for severe mental health disorders
Current expenditure on health by general government and compulsory schemes as percentage of total current expenditure on
health
Rate of use of assistive devices among people with disabilities
Proportion of newborns receiving essential newborn care
30-day hospital case fatality rate – acute myocardial infarction
Patient experience (to be defined)
Proportion of health-care facilities with basic water supply
Proportion of health-care facilities with basic sanitation
Hospital average length of stay
Dengue mortality rate
Mortality rate attributable to hepatitis B virus (HBV) and hepatitis C virus (HCV) infections
Proportion of deliveries in health facilities
Age-standardized prevalence of current tobacco use among persons aged 13–15 years
Outpatient service utilization rate
Cataract surgical rate and coverage
Postoperative sepsis rate
Hospital readmission rate
Proportion of the population utilizing the rehabilitation services they require
HIV testing coverage among people living with HIV
Viral suppression rate among people on ART
51
Appendix 3. WHO Western Pacific Region mapping of SDG and UHC indicators
Table A. Health indicators in SDG 3 mapped to the SDG and UHC Regional Monitoring Framework
Health indicators in SDG 3 mapped to the SDG and UHC Regional Monitoring Framework
Monitoring Domain Indicator domain Indicator

Health impact Mortality 3.1.1 Maternal mortality ratio
through the life 3.2.1 Under-5 mortality rate
course 3.2.2 Neonatal mortality rate
3.4.1 Mortality rate attributed to cardiovascular disease, cancer, diabetes or
chronic respiratory disease
3.4.2 Suicide mortality rate
3.6.1 Death rate due to road traffic injuries
3.9.1 Mortality rate attributed to household and ambient air pollution
3.9.2 Mortality rate attributed to unsafe water, unsafe sanitation, and lack of
hygiene (exposure to unsafe WASH services)
3.9.3 Mortality rate attributed to unintentional poisoning
Morbidity 3.3.1 Number of new HIV infections per 1000 uninfected population, by sex, age
and key populations
3.3.2 Tuberculosis incidence per 100 000 population
3.3.3 Malaria incidence per 1000 population
3.3.4 Hepatitis B incidence per 100 000 population
Life expectancy and 3.7.2 Adolescent birth rate (aged 10–14 years; aged 15–19 years) per 1000
well-being women in that age group
Determinants of Individual 3.5.2 Harmful use of alcohol, defined according to the national context as
health characteristics and alcohol per capita consumption (aged 15 years and older) within a calendar year
behaviours in litres of pure alcohol
3.a.1 Age-standardized prevalence of current tobacco use among persons aged
15 years and older
Universal health Health service 3.3.5 Number of people requiring interventions against neglected tropical
coverage coverage diseases
3.5.1 Coverage of treatment interventions (pharmacological, psychosocial, and
rehabilitation and aftercare services) for substance use disorders
3.7.1 Proportion of women of reproductive age (aged 15–49 years) who have
their need for family planning satisfied with modern methods
3.8.1 Coverage of essential health services (defined as the average coverage
of essential services based on tracer interventions that include reproductive,
maternal, newborn and child health; infectious disease; noncommunicable
diseases; and service capacity and access, among the general and the most
disadvantaged population)
3.b.1 Proportion of the target population covered by all vaccines included in
their national programme
3.1.2 Proportion of births attended by skilled health personnel
Financial protection 3.8.2 Proportion of population with large household expenditures on health as a
share of total household expenditure or income
Health system Resources and 3.b.2 Total net official development assistance to the medical research and basic
resources and infrastructure health sectors
capacity 3.c.1 Health worker density and distribution
Availability and 3.b.3 Proportion of health facilities that have a core set of relevant essential
readiness medicines available and affordable on a sustainable basis
3.d.1 International Health Regulations (2005) capacity and health emergency
preparedness
52
APPENDICES
Table B. Health indicators in other SDG mapped to the SDG and UHC Regional Monitoring Framework
Health indicators in SDG 3 mapped to the SDG and UHC Regional Monitoring Framework
Monitoring Domain Indicator domain Indicator

Health impact Mortality 1.5.1
through the life 11.5.1
course 13.1.1 Number of deaths, missing persons and directly affected persons
attributed to disasters per 100 000 population
16.1.1 Number of victims of intentional homicide per 100 000 population, by sex
and age
16.1.2 Conflict-related deaths per 100 000 population, by sex, age and cause
Morbidity 2.2.1 Prevalence of stunting (height for age < –2 standard deviation from the
median of WHO Child Growth Standards) among children under 5 years of age
2.2.2 Prevalence of malnutrition (weight for height > +2 or < –2 standard
deviation from the median of the WHO Child Growth Standards) among children
under 5 years of age, by type (wasting and overweight)
Determinants of Social environment 5.2.1 Proportion of ever-partnered women and girls aged 15 years and older
health factors subjected to physical, sexual or psychological violence by a current or former
intimate partner in the previous 12 months, by form of violence and by age
5.2.2 Proportion of women and girls aged 15 years and older subjected to sexual
violence by persons other than an intimate partner in the previous 12 months, by
age and place of occurrence
16.1.3 Proportion of the population subjected to physical, psychological or sexual
violence in the previous 12 months
16.2.1 Proportion of children aged 1–17 years who experienced any physical
punishment and/or psychological aggression by caregivers in the past month
16.2.2 Number of victims of human trafficking per 100 000 population, by sex,
age and form of exploitation
16.2.3 Proportion of young women and men aged 18–29 years who experienced
sexual violence by age 18
Physical environment 6.1.1 Proportion of population using safely managed drinking-water services
factors 6.2.1 Proportion of population using safely managed sanitation services,
including a handwashing facility with soap and water
7.1.2 Proportion of population with primary reliance on clean fuels and
technology
11.6.2 Annual mean levels of fine particulate matter (e.g. PM2.5 and PM10) in
cities (population weighted)
Universal health Financial protection 1.3.1 Proportion of population covered by social protection floors/systems, by
coverage sex, distinguishing children, unemployed persons, older persons, persons with
disabilities, pregnant women, newborns, work injury victims and the poor and
the vulnerable
Health system Resources and 16.9.1 Proportion of children under 5 years of age whose births have been
resources and infrastructure registered with a civil authority, by age
capacity 17.19.2(b) Proportion of countries that have achieved 100% birth registration
and 80% death registration
Responsiveness and 5.6.2 Number of countries with laws and regulations that guarantee full
People-centredness and equal access to women and men aged 15 years and older to sexual and
reproductive health care, information and education
Health financing 1.a.2 Proportion of total government spending on essential services (education,
health and social protection)
53
Table C. Additional indicators to monitor UHC mapped to the SDG and UHC Regional Monitoring Framework
Additional indicators to monitor UHC mapped to the SDG and UHC Regional Monitoring Framework
Monitoring
Indicator domain Indicator
Domain
Health impact Mortality Dengue mortality rate
through the life Mortality rate attributable to HBV and HCV infections
course Stillbirth rate (per 1000 total births)
Morbidity Incidence of low birth weight among newborns
Anaemia prevalence in women of reproductive age (aged 15–49 years)
Prevalence of anaemia in children aged 6–59 months
Case rate of congenital syphilis (per 100 000 live births)
Life expectancy and Life expectancy at birth
well-being
Determinants of Individual Age-standardized prevalence of raised blood glucose level among adults 18+ years
health characteristics and Age-standardized prevalence of raised blood pressure among persons aged 18+ years
behaviours Age-standardized prevalence of overweight and obesity in persons aged 18+ years
Age-standardized prevalence of insufficiently physically active persons aged 18+ years
Seat belt–wearing rate
Motorcycle helmet–wearing rate
Age-standardized prevalence of current tobacco use among persons aged 13–15 years
Percentage of children under 5 years of age with suspected pneumonia who were taken
to a health facility
Exclusive breastfeeding rate in infants 0–5 months of age
Universal health Use/Accessibility Rate of use of assistive devices among people with disabilities
coverage Proportion of the population utilizing the rehabilitation services they require
Outpatient service utilization rate
Health service Coverage of services for severe mental health disorders
coverage HIV testing coverage among people living with HIV
Cervical cancer screening (rate)
ART coverage
Second-line treatment coverage among MDR-TB cases
Proportion of deliveries in health facilities
Health system Effectiveness Immunization coverage rate for DTP3 (diphtheria-tetanus-pertussis)
resources and Immunization coverage rate for measles
capacity Viral suppression rate among people on ART
Proportion of newborns receiving essential newborn care
Cataract surgical rate and coverage
Quality and safety 30-day hospital case fatality rate – acute myocardial infarction
Post-operative sepsis rate
Hospital readmission rate
Responsiveness and Patient experience (to be defined)
people-centredness
Resources and Proportion of health-care facilities with basic water supply
infrastructure Proportion of health-care facilities with basic sanitation
Efficiency and Bed occupancy rate
sustainability Hospital average length of stay
Health financing Total current expenditure on health as percentage of gross domestic product
Current expenditure on health by general government and compulsory schemes as a
percentage of total current expenditure on health
54
APPENDICES
Appendix 4. Reference list: 88 SDG and UHC health indicators listed according to the health system results chain
(logic model)
Inputs and Processes Outputs Outcomes Impact

• Total net official • International Health • Proportion of births attended by skilled health personnel • Maternal mortality ratio
development assistance to Regulations (2005) • Number of people requiring interventions against • Under-5 mortality rate
the medical research and capacity and health neglected tropical diseases • Neonatal mortality rate
basic health sectors emergency preparedness • Coverage of treatment for substance use disorders • Number of new HIV infections per
• Health worker density and • Outpatient service • Harmful use of alcohol 1000 uninfected population
distribution utilization rate • Proportion of women reproductive age (aged 15–49 • Malaria incidence per 1000 population
• Proportion of children • Postoperative sepsis rate years) who have their need for family planning satisfied • Hepatitis B incidence per 100 000
under 5 years of age • Bed occupancy rate with modern methods population
whose births have been • 30-day hospital case • Adolescent birth rate • Suicide mortality rate
registered with a civil fatality rate – acute • Coverage of essential health services
authority • Death rate due to road traffic injuries
myocardial infarction • Proportion of population with large household • Mortality rate attributed to
• Proportion of countries • Patient experience (to be expenditure on health as a share of total household
that have achieved 100% cardiovascular disease, cancer,
defined) expenditure or income diabetes or chronic respiratory disease
birth registration and 80% • Hospital average length
death registration • Age-standardized prevalence of current tobacco use • Tuberculosis incidence per 100 000
of stay among persons aged 15 years and older population
• Total current expenditure • Hospital readmission rate
on health as percentage of • Proportion of the target population covered by all • Mortality rate attributed to household
gross domestic product vaccines included in their national programme and ambient air pollution
• Current expenditure • Proportion of population covered by social protection • Mortality rate attributed to unsafe
on health by general floors/systems water, unsafe sanitation, and lack of
government and • Prevalence of stunting among children under 5 years hygiene
compulsory schemes as of age • Mortality rate attributed to
percentage of total current • Prevalence of malnutrition among children under 5 years unintentional poisoning
expenditure on health of age, by type (wasting and overweight) • Proportion of health facilities that
• Proportion of health-care • Proportion of population using safely managed drinking- have a core set of relevant essential
facilities with basic water water services medicines available and affordable on
supply • Proportion of population using safely managed sanitation a sustainable basis
• Proportion of health-care services, including a handwashing facility with soap • Number of deaths, missing persons
facilities with basic and water and directly affected persons
sanitation • Annual mean levels of fine particulate matter (e.g. PM2.5 attributed to disasters per 100 000
• Proportion of total and PM10) in cities (population weighted) population
government spending • Proportion of population with primary reliance on clean • Proportion of women and girls aged
on essential services fuels and technology 15 years and older subjected to sexual
(education, health and • Proportion of ever-partnered women and girls aged violence by persons other than an
social protection) 15 years and older subjected to physical, sexual or intimate partner in the previous 12
psychological violence by a current or former intimate months
partner in previous 12 months • Number of countries with laws and
• Seat belt-wearing rate regulations that guarantee full and
• Motorcycle helmet-wearing rate equal access to women and men
• Immunization coverage for DTP3 (diphtheria-tetanus- aged 15 years and older to sexual and
pertussis) reproductive health care, information
and education
• Immunization coverage rate for measles
• Number of victims of intentional
• Exclusive breastfeeding rate in infants 0–5 months of age homicide per 100 000 population
• Incidence of low birth weight among newborns • Conflict-related deaths per 100 000
• Prevalence of anaemia in children aged 6–59 months population
• Anaemia prevalence in women of reproductive age (aged • Proportion of population subjected
15–49 years) to physical, psychological or sexual
• Age-standardized prevalence of raised blood glucose level violence in the previous 12 months
among adults 18+ years • Proportion of children aged 1–17
• Age-standardized prevalence of overweight and obesity years who experienced any physical
in persons aged 18+ years punishment and/or psychological
• Age-standardized prevalence of raised blood pressure aggression by caregivers in the past
among persons aged 18+ years month
• Age-standardized prevalence of insufficiently physically • Number of victims of human
active persons aged 18+ years trafficking per 100 000 population
• Percentage of children under 5 years of age with • Proportion of young women and men
suspected pneumonia who were taken to a health facility aged 18–29 years who experienced
• Antiretroviral therapy (ART) coverage sexual violence by age 18
• Second-line treatment coverage among multidrug- • Life expectancy at birth
resistant tuberculosis (MDR-TB) cases • Stillbirth rate (per 1000 total births)
• Cervical cancer screening (rate) • Case rate of congenital syphilis (per
• Coverage of services for severe mental health disorders 100 000 live births)
• Rate of use of assistive devices among people with • Mortality rate attributable to HBV and
disabilities HCV infections
• Proportion of newborns receiving essential newborn care • Dengue mortality rate
• Proportion of deliveries in health facilities
• Age-standardized prevalence of current tobacco use
among persons aged 13–15 years
• Cataract surgical rate and coverage
• Proportion of population utilizing the rehabilitation
services they require
• HIV testing coverage among people living with HIV
• Viral suppression rate among people on ART
55
Appendix 5. Examples of Metadata for 16 tracer indicators (UHC service coverage index)63
Reproductive, maternal, newborn and child health

Tracer area Family planning
Indicator definition Percentage of women of reproductive age (15−49 years) who are married or in-union who have their need for
family planning satisfied with modern methods
Numerator Number of women aged 15–49 who are married or in-union who use modern methods
Denominator Total number of women aged 15–49 who are married or in-union in need of family planning
Main data sources Population-based health surveys
Method of Household surveys include a series of questions to measure modern contraceptive prevalence rate and demand
measurement for family planning. Total demand for family planning is defined as the sum of the number of women of
reproductive age (15–49 years) who are married or in a union and who are currently using – or whose sexual
partner is currently using – at least one contraceptive method, and the unmet need for family planning. Unmet
need for family planning is the proportion of women of reproductive age (15–49 years) either married or in
a consensual union, who are fecund and sexually active but who are not using any method of contraception
(modern or traditional), and report not wanting any more children or wanting to delay the birth of their next
child for at least two years. Included are:
1. all pregnant women (married or in a consensual union) whose pregnancies were unwanted or mistimed
at the time of conception;
2. all postpartum amenorrhoeic women (married or in consensual union) who are not using family planning
and whose last birth was unwanted or mistimed; and
3. all fecund women (married or in consensual union) who are neither pregnant nor postpartum
amenorrhoeic, and who either do not want any more children (want to limit family size), or who wish
to postpone the birth of a child for at least two years or do not know when or if they want another child
(want to space births), but are not using any contraceptive method.
Method of The United Nations Population Division produces a systematic and comprehensive series of annual estimates
estimation and projections of the percentage of demand for family planning that is satisfied among married or in-union
women. A Bayesian hierarchical model combined with country-specific data are used to generate the estimates,
projections and uncertainty assessments from survey data. The model accounts for differences by data source,
sample population, and contraceptive methods.
See here for details:
http://www.un.org/en/development/desa/population/theme/family-planning/cp_model.shtml
UHC-related notes
Tracer area Pregnancy and delivery care

Indicator definition Percentage of women aged 15–49 years with a live birth in a given time period who received antenatal care
four or more times
Numerator Number of women aged 15−49 years with a live birth in a given time period who received antenatal care four or
more times
Denominator Total number of women aged 15−49 years with a live birth in the same period
Main data sources Household surveys and routine facility information systems
Method of Data on four or more antenatal care visits is based on questions that ask if and how many times the health
measurement of the woman was checked during pregnancy. Household surveys that can generate this indicator include
demographic health surveys, multiple indicator cluster surveys, reproductive health surveys and other surveys
based on similar methodologies. Service/facility reporting systems can be used where the coverage is high,
usually in higher-income countries.
Method of WHO maintains a data base on coverage of antenatal care: http://www.who.int/gho/maternal_health/
estimation who_rhr_anc4_detailed_2017.xls
UHC-related notes Ideally this indicator would be replaced with a more comprehensive measure of pregnancy and delivery
care, for example, the proportion of women who receive both 4+ antenatal care visits and have a skilled
provider attend the birth or have an institutional delivery. A challenge in measuring skilled attendance at
birth is determining which providers are “skilled”. WHO and UNICEF are currently leading a process to come
to agreement across countries about the definition of a skilled provider, after which a more comprehensive
indicator of pregnancy and delivery care could be incorporated into the index. Once comparable values are
available across countries, SDG 3.1.2 could be used.
63
As of 28 February 2017.
56
APPENDICES
Tracer area Full child immunization

Indicator definition Percentage of infants receiving three doses of diphtheria-tetanus-pertussis-containing vaccine (DTP3).
Numerator Children 1 year of age who have received three doses of DTP3.
Denominator All children 1 year of age.
Main data sources Household surveys and facility information systems.
Method of For survey data, the vaccination status of children aged 12–23 months is collected from child health cards or, if
measurement there is no card, from recall by the caretaker. For administrative data, the total number of doses administered to
the target population is extracted.
Method of Together, WHO and UNICEF derive estimates of DTP3 coverage based on data officially reported to WHO and
estimation UNICEF by Member States, as well as data reported in the published and grey literature. They also consult with
local experts – primarily national Expanded Programme on Immunization (EPI) managers and WHO Regional
Office staff – for additional information regarding the performance of specific local immunization services.
Based on the available data, consideration of potential biases, and contributions from local experts, WHO/
UNICEF determine the most likely true level of immunization coverage.
For details, see here:
http://www.who.int/bulletin/volumes/87/7/08-053819/en/
http://www.who.int/immunization/monitoring_surveillance/routine/coverage/en/index4.html
UHC-related notes There is variability in national vaccine schedules across countries. Given this, one option for monitoring
full child immunization is to monitor the fraction of children receiving vaccines included in their country’s
national schedule. A second option, which may be more comparable across countries and time, is to monitor
DTP3 coverage as a proxy for full child immunization. Diphtheria-tetanus-pertussis-containing vaccine often
includes other vaccines, e.g. against hepatitis B and Haemophilus influenza type B, and is a reasonable measure
of the extent to which there is a robust vaccine delivery platform within a country. The vaccine coverage
indicator for SDG target 3.b is still under development, but once available could be adopted in lieu of DTP3
coverage as part of the UHC service coverage index in future years.
Tracer area Child treatment (care seeking for symptoms of pneumonia)

Indicator definition Percentage of children under 5 years of age with suspected pneumonia (cough and difficult breathing not due
to a problem in the chest and a blocked nose) in the two weeks preceding the survey taken to an appropriate
health facility or provider.
Numerator Number of children with suspected pneumonia in the two weeks preceding the survey taken to an appropriate
health provider.
Denominator Number of children with suspected pneumonia in the two weeks preceding the survey.
Main data sources Household surveys
Method of During the UNICEF/WHO Meeting on Child Survival Survey-based Indicators held in New York, 17–18 June 2004,
measurement it was recommended that acute respiratory infections (ARI) be described as “presumed pneumonia” to better
reflect probable cause and the recommended interventions. The definition of presumed pneumonia used in
the DHS and MICS was chosen by the group and is based on mothers’ perceptions of a child who has a cough, is
breathing faster than usual with short, quick breaths, or is having difficulty breathing, excluding children that
had only a blocked nose. The definition of “appropriate” care provider varies between countries.
WHO maintains a data base of country-level observations from household surveys that can be accessed here:
http://www.who.int/gho/child_health/prevention/pneumonia/en/
Method of There are currently no internationally comparable estimates for this indicator.
estimation
UHC-related notes This indicator is not typically measured in higher-income countries with well-established health systems.
For countries without observed data, coverage was estimated from a regression that predicts coverage of care
seeking for symptoms of pneumonia (on the logit scale), obtained from the WHO database described above, as
a function of the log of the estimated under-five pneumonia mortality rate, which can be found here: http://
www.who.int/healthinfo/global_burden_disease/
57
Communicable diseases
Tracer area Tuberculosis detection and treatment
Indicator definition Percentage of incidence TB cases that are detected and successfully treated in a given year
Numerator Number of new and relapse cases detected in a given year and successfully treated
Denominator Number of new and relapse cases in the same year
Main data sources Facility information systems, surveillance systems, population-based health surveys with TB diagnostic testing,
TB register and related quarterly reporting system (or electronic TB registers)
Method of This indicator requires three main inputs:
measurement 1. The number of new and relapse TB cases diagnosed and treated in national TB control programmes and
reported to WHO in a given year.
2. The number of incident TB cases for the same year, typically estimated by WHO.
3. Percentage of TB cases successfully treated (cured plus treatment completed) among TB cases reported to
the national health authorities.
The final indicator = (1)/(2) x (3)
Method of Estimates of TB incidence are produced through a consultative and analytical process led by WHO and are
estimation published annually. These estimates are based on annual case notifications, assessments of the quality and
coverage of TB notification data, national surveys of the prevalence of TB disease and information from death
(vital) registration systems. Estimates of incidence for each country are derived, using one or more of the
following approaches depending on available data:
1. incidence = case notifications/estimated proportion of cases detected;
2. incidence = prevalence/duration of condition;
3. incidence = deaths/proportion of incident cases that die.
These estimates of TB incidence are combined with country-reported data on the number of cases detected and
treated, and the percentage of cases successfully treated, as described above.
UHC-related notes To compute the indicator using WHO estimates, one can access necessary files
here: http://www.who.int/tb/country/data/download/en/, and compute the indicator
as = c_cdr x c_new_tsr
Tracer area HIV treatment

Indicator definition Percentage of people living with HIV currently receiving antiretroviral therapy (ART)
Numerator Number of adults and children who are currently receiving ART at the end of the reporting period
Denominator Number of adults and children living with HIV during the same period
Main data sources Facility-reporting systems, sentinel surveillance sites, population-based surveys
Method of Numerator: The numerator can be generated by counting the number of adults and children who received
measurement antiretroviral combination therapy at the end of the reporting period. Data can be collected from facility-based
ART registers or drug supply management systems. These are then tallied and transferred to cross-sectional
monthly or quarterly reports that can then be aggregated for national totals. Patients receiving ART in the
private sector and public sector should be included in the numerator.
Denominator: Data on the number of people with HIV infection may come from population-based surveys or, as
is common in sub-Saharan Africa, surveillance systems based on antenatal care clinics.
Method of Estimates of ART treatment coverage among people living with HIV in 2015 are derived as part of the 2016
estimation UNAIDS’ estimation round or, in some limited instances, taken from data submitted to UNAIDS through the
Global AIDS Response Progress Reporting tool.
To estimate the number of people living with HIV across time in high-burden countries, UNAIDS in collaboration
with countries uses an epidemic model (Spectrum) that combines surveillance data on prevalence with the
current number of patients receiving ART and assumptions about the natural history of HIV disease progression.
Since ART is now recommended for all individuals living with HIV, monitoring ART coverage is less complicated
than before, when only those with a certain level of disease severity were eligible to receive ART.
Estimates of ART coverage can be found here: http://aidsinfo.unaids.org/
UHC-related notes Comparable estimates of ART coverage in high-income countries, in particular
time trends, are not always available.
58
APPENDICES
Tracer area Insecticide-treated bed nets (ITN) coverage for malaria prevention
Indicator definition Percentage of population in malaria-endemic areas who slept under an ITN the previous night.
Numerator Number of people in malaria-endemic areas who slept under an ITN.
Denominator Total number of people in malaria-endemic areas.
Main data sources Data on household access and use of ITNs come from nationally representative household surveys such
as DHS, MICS, and Malaria Indicator Surveys. Data on the number of ITNs delivered by manufacturers to
countries are compiled by Milliner Global Associates, and data on the number of ITNs distributed within
countries are reported by National Malaria Control Programs.
Method of measurement Many recent national surveys report the number of ITNs observed in each respondent household.
Ownership rates can be converted to the proportion of people sleeping under an ITN using a linear
relationship between access and use that has been derived from 62 surveys that collect information on
both indicators.
Method of estimation Mathematical models can be used to combine data from household surveys on access and use with
information on ITN deliveries from manufacturers and ITN distribution by national malaria programmes
to produce annual estimates of ITN coverage. WHO uses this approach in collaboration with the Malaria
Atlas Project. Methodological details can be found in the Annex of the World Malaria Report 2015:
http://www.who.int/malaria/publications/world-malaria-report-2015/report/en/.
UHC-related notes WHO produces comparable ITN coverage estimates for 40 high-burden countries. For other countries,
ITN coverage is not included in the UHC service coverage index due to data limitations. However, future
research will focus on estimating ITN coverage among those at risk in countries outside of Africa with
(potentially localized) malaria burden.
Tracer area Improved water and adequate sanitation source

Indicator definition Percentage of households using improved sanitation facilities
Numerator Population living in a household with: flush or pour-flush to piped sewer system, septic tank or pit
latrine, ventilated improved pit latrine, pit latrine with slab, or composting toilet.
Denominator Total population
Main data sources Population-based household surveys and censuses
Method of measurement Household-level responses, weighted by household size, are used to compute population coverage.
Method of estimation The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) has produced
regular estimates of coverage of improved sanitation for MDG monitoring. After compiling a database
of available data sources for each country, simple linear regressions are fitted to the country’s data
series to obtain an in-sample estimate, as well as to produce a two-year extrapolation beyond the last
available data point, after which coverage is held constant for four years and then assumed missing.
This is done separately for urban and rural regions, and then combined to obtain national coverage
estimates. Details of the methodology and most recent estimates can be found here: http://www.
wssinfo.org/.
UHC-related notes The SDG indicator for sanitation (SDG 6.2.1) is an expanded version of the MDG indicator, incorporating
the quality of sanitation facilities. Once country data and estimates are available for this new indicator,
it could be used for UHC monitoring in lieu of the MDG indicator definition described above. A joint
indicator that identifies the proportion of households with access to both safe water and sanitation
could also be considered.
59
Noncommunicable diseases
Tracer area Treatment of cardiovascular disease
Indicator definition Age-standardized prevalence of non-raised blood pressure among adults aged 18+
Numerator Number of adults aged 18 or older without systolic blood pressure (SBP) ≥140 mmHg and diastolic blood
pressure (DBP) ≥90 mmHg
Denominator Number of adults aged 18 or older
Main data sources Population-based surveys and surveillance systems
Method of Data sources recording measured blood pressure are used (self-reported data are excluded). If multiple blood
measurement pressure readings are taken per participant, the first reading is dropped and the remaining readings are
averaged.
Method of For producing comparable national estimates, data observations of prevalence defined in terms of alternate
estimation SBP and/or DBP cutoffs are converted into prevalence of SBP ≥140 mmHg or DBP ≥90 mmHg using regression
equations. A Bayesian hierarchical model is then fitted to these data to calculate age-sex-year-country-specific
prevalences, which accounts for national versus subnational data sources, urban versus rural data sources,
and allows for variation in prevalence across age and sex. Age-standardized estimates are then produced by
applying the crude estimates to the WHO Standard Population. Details on the statistical methods are here:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31919-5/fulltext.
WHO and the NCD Risk Factor Collaboration (NCD-RisC) has produced comparable estimates for this
indicator up through year 2015, which are available here: http://apps.who.int/gho/data/node.main.
A875STANDARD?lang=en.
UHC-related notes Prevalence estimates are converted to the prevalence of non-raised blood pressure for incorporation into
the UHC index, so that a value of 100% is the optimal target. This is computed as: non-raised blood pressure
prevalence = 1 – raised blood pressure prevalence.
As more data become available, this indicator will likely be replaced by the fraction of population with
hypertension receiving effective treatment. For now, prevalence of non-raised blood pressure is used as a proxy
measure of the effective coverage of prevention and treatment of hypertension. The above estimates are done
separately for men and women; for the UHC tracer indicator a simple average of values for men and women is
computed.
Tracer area Management of diabetes

Indicator definition Age-standardized mean fasting plasma glucose (FPG) for adults aged 25 years and older
Main data sources Population-based surveys and surveillance systems
Method of FPG levels are determined by taking a blood sample from participants who have fasted for at least 8 hours.
measurement Other related biomarkers, such as haemoglobin A1c (HbA1c), were used to help calculate estimates (see below).
Method of For producing comparable national estimates, data observations based on mean FPG, oral glucose tolerance
estimation test (OGTT), HbA1c, or combinations therein, are all converted to mean FPG. A Bayesian hierarchical model is
then fitted to these data to calculate age-sex-year-country-specific prevalences, which accounts for national
versus subnational data sources, urban versus rural data sources, and allows for variation in prevalence across
age and sex. Age-standardized estimates are then produced by applying the crude estimates to the WHO
Standard Population. Methodological details can be found here:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60679-X/abstract
UHC-related notes As more data become available, this indicator will likely be replaced by the fraction of population with diabetes
under treatment. For now, mean FPG is used as a proxy measure of the effective coverage of prevention and
treatment of diabetes. The above estimates are done separately for men and women; for the UHC tracer
indicator a simple average of values for men and women is computed.
60
APPENDICES
Tracer area Cervical cancer screening

Indicator definition Percentage of women aged 30−49 years who report ever having been screened for cervical cancer
Numerator Number of women aged 30−49 years who report ever having had a screening test for cervical cancer using any
of these methods: visual inspection with acetic acid (VIA), pap smear and human papillomavirus (HPV) test.
Denominator All women aged 30–49 years
Main data sources Population-based surveys
Method of Self-reported data on respondents’ cervical cancer screening history are collected through surveys.
measurement
Method of There are currently no comparable estimates of cervical cancer screening coverage.
estimation
UHC-related notes There are currently few countries with recent data for this indicator and it is therefore excluded from the UHC
service coverage index calculations. An additional challenge for international comparability is that data sources
may use different time periods (ever screened versus screened in past 5 years) and different age groups.
Tracer area Tobacco control

Indicator definition Age-standardized prevalence of adults ≥15 years old not smoking tobacco in last 30 days
Numerator Adults 15 years and older who have not smoked tobacco in the last 30 days
Denominator Adults 15 years and older
Main data sources Household surveys
Method of “Current tobacco smoking” includes cigarettes, cigars, pipes or any other smoked tobacco products used in the
measurement past 30 days. Data are collected via self-report in surveys.
Method of WHO estimates prevalence of current tobacco (non) smoking with a negative binomial meta-regression model,
estimation which generates comparable estimates by adjusting for differences in age groups and indicator definition
across national surveys included in the analysis. These estimates are done separately for men and women.
Methodological details can be found here: http://www.thelancet.com/journals/lancet/article/PIIS0140-
6736(15)60264-1/supplemental.
WHO estimates of the prevalence of tobacco smoking can be accessed here (see “current smoking of any tobacco
product”): http://apps.who.int/gho/data/node.main.1250?lang=en.
UHC-related notes Prevalence of not smoking tobacco is computed as 1 minus the prevalence of tobacco smoking.
61
Service capacity and access

Tracer area Hospital access
Indicator definition Hospital beds per capita, relative to a maximum threshold of 18 per 10 000 population
Numerator Number of hospital beds (should exclude labour and delivery beds)
Main data sources Administrative systems/health facility reporting system
Method of Country administrative systems are used to total the number of hospital beds, which are divided by the total
measurement estimated population, and multiplied by 10 000.
WHO regional offices and other groups collect information on national hospital bed density, including the
following online resources:
WHO Regional Office for the Eastern Mediterranean Regional Health Observatory: https://rho.emro.who.int/
rhodata/node.main.A36
WHO Regional Office for Africa Regional Health Observatory:
http://www.aho.afro.who.int/en/data-
statistics/hospital-beds-10-000-population
WHO Regional Office for South-East Asia Health Information Platform (HIP):
http://hip.searo.who.int/dhis/dhis-web-commons/security/login.action
WHO European Health Information Gateway:
http://gateway.euro.who.int/en/data-sources/european-database-on-human-and-
technical-resources-for-health/
OECD:
http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-asia-pacific-2014_health_
glance_ap-2014-en
Method of Using available data, the indicator is computed relative to a threshold value of 18 hospital beds per 10 000
estimation population. This threshold is below the observed OECD high-income country minimum (since year 2000) of 20
per 10 000 and tends to correspond to an inpatient hospital admission rate of around 5 per 100 per year.
This indicator is designed to capture low levels of hospital capacity; the maximum threshold is used because
very high hospital bed densities are not necessarily an efficient use of resources. The indicator is computed as
follows, using country data on hospital bed density (x), which results in values ranging from 0 to 100:
• Country with a hospital bed density x < 18 per 10 000 per year, the indicator = x /18*100.
• Country with a hospital bed density x ≥ 18 per 10 000 per year, the indicator = 100.
UHC-related notes An alternative indicator could be hospital inpatient admission rate, relative to a maximum threshold. However,
that indicator is currently not reported widely across regions, in particular in the African Region.
Tracer area Access to essential medicines

Indicator definition Percentage of health facilities with essential medicines
Numerator Number of facilities with essential medicines in stock
Denominator Total number of health facilities
Main data sources Special facility surveys or, potentially, routine facility information systems
Method of Data on the availability of a specific list of medicines are collected from a survey of a sample of facilities.
measurement Availability is reported as the percentage of medicine outlets where a particular medicine was found on the day
of the survey. If routine facility reporting on stocks is accurate and complete, it may also be possible to use data
from the routine system. Regular independent verification is required.
Method of This indicator is still under development, both in terms of the core list of medicines to be monitored and data
estimation collection strategies. The Service Availability and Readiness Assessment (SARA) surveys have collected data for
a limited number of countries; see here: http://www.who.int/healthinfo/systems/sara_methods/en/.
UHC-related notes There are currently about 30 countries with recent data on access to essential medicines, and it is therefore excluded
from the UHC service coverage index calculations. Importantly, the SDG-IAEG has recently recommended that,
under target 3.b, there be separate indicators for vaccines and access to essential medicines. If adopted by the UN
Statistical Commission, a definition and metadata for an SDG indicator on access to essential medicines will be
completed. Once reporting on this indicator begins, it can be used in the UHC index.
62
APPENDICES
Tracer area Health workforce

Indicator definition Health professionals (physicians, psychiatrists and surgeons) per capita, relative to maximum thresholds for
each cadre
Numerator Number of physicians, psychiatrists and surgeons
Main data sources National database or registry of health workers, ideally coupled with regular assessment of completeness using
census data, professional association registers, or facility censuses.
Method of The classification of health workers is based on criteria for vocational education and training, regulation
measurement of health professions, and activities and tasks of jobs, i.e. a framework for categorizing key workforce
variables according to shared characteristics. The WHO framework largely draws on the latest revisions to the
internationally standardized classification systems of the International Labour Organization (International
Standard Classification of Occupations); United Nations Educational, Scientific and Cultural Organization
(International Standard Classification of Education); and the United Nations Statistics Division (International
Standard Industrial Classification of All Economic Activities). Methodological details and data can be found
here: http://www.who.int/hrh/statistics/hwfstats/en/
Method of Using available data, the indicator is computed by first rescaling, separately, health worker density ratios for
estimation each of the three cadres (physicians, psychiatrists and surgeons) relative to the minimum observed values
across OECD countries since 2000, which are as follows: physicians = 0.9 per 1000, psychiatrists = 1 per 100 000,
and surgeons = 14 per 100 000. This rescaling is done in the same way as that for the hospital bed density
indicator described above, resulting in indicator values that range from 0 to 100 for each of the three cadres.
For example, using country data on physicians per 1000 population (x), the cadre-specific indicator would be
computed as:
• Country with x < 0.9 per 1000 per year, the cadre-specific indicator = x /0.9*100
• Country with x ≥ 0.9 per 1000 per year, the cadre-specific indicator = 100.
As a final step, the geometric mean of the three cadre-specific indicator values is computed to obtain the final
indicator of health workforce density.
UHC-related notes The “physicians” category would ideally be expanded to include all “core health professionals”, such as nurses
and midwives. However, no internationally comparable database exists that uses consistent definitions of non-
physician core health professionals to allow for fully accurate cross-country comparisons. Work on measuring
SDG indicator 3.c.1 could resolve this issue and allow for a more comprehensive indicator.
Tracer area Health security

Indicator definition International Health Regulations (2005) core capacity index, which is the average percentage of attributes of 13
core capacities that have been attained at a specific point in time.
The 13 core capacities are: (1) National legislation, policy and financing; (2) Coordination and National Focal
Point communications; (3) Surveillance; (4) Response; (5) Preparedness; (6) Risk communication; (7) Human
resources; (8) Laboratory; (9) Points of entry; (10) Zoonotic events; (11) Food safety; (12) Chemical events; (13)
Radionuclear emergencies.
Numerator Number of attributes attained
Denominator Total number of attributes
Main data sources Key informant survey
Method of Key informants report on attainment of a set of attributes for each of 13 core capacities using a standard WHO
measurement instrument, as described here: http://apps.who.int/iris/bitstream/10665/84933/1/WHO_HSE_GCR_2013.2_eng.
pdf
Capacity-level indicator values can be found here:
http://www.who.int/gho/ihr/monitoring/legislation/en/index1.html
Method of The indicator is computed by averaging, across the 13 core capacities, the percentage of attributes for each
estimation capacity that have been attained.
UHC-related notes
63
Appendix 6. Additional focus areas for indicator development (mapped to the SDG and UHC Regional Monitoring
Framework)
Focus area Indicator domain Details
Disability-specific and • Effectiveness To the extent possible, within the limits of data availability and quality, process
community-based • Quality and and output indicators will be used to assess the quality, effectiveness and equity of
rehabilitation safety community-based rehabilitation interventions, especially at the country level.64
We need to be able to count people with disabilities to quantify service and support
needs, to study the life course of people with specific disabilities, and to accurately
target prevention strategies. While starting with measurement of disability
prevalence, we need to move towards data sources that can inform functionality.
Healthy life expectancy • Life expectancy If it could be measured reliably, healthy life expectancy would be a useful indicator,
and well-being showing both mortality and years of life lived in less than good health, i.e.
disability, which is affected by all health and health-related programmes. Healthy
life expectancy can be measured accurately, based on complete death registration
systems, with an equity dimension. It is well understood and widely used.
Health system • Quality and This area takes account of the five UHC attributes and enables systemic standardized
performance safety measurement of performance, public reporting of data and the use of performance
• Efficiency and data to catalyze policy change. The results may be presented in the form of league
sustainability tables or report cards.
• Quality and safety indicators. Some countries in the region, including
Australia, Japan, the Republic of Korea and Singapore, have developed or are
developing indicators to monitor service quality and patient safety in hospitals.
Indicators currently captured in the monitoring framework include 30-day
hospital case fatality rate for acute myocardial infarction, postoperative sepsis
as a percentage of all surgical procedures, and the hospital readmission rate.
Potentially preventable hospitalizations and a composite index for quality
may also be considered. Other safety measurements may include hand
hygiene, compliance and safe surgery. Insurance data, hospital performance
assessment and pay for performance data may be better linked with service
quality assessments conducted by health insurance agencies. Data may be
strengthened in the area of primary health care. OECD is also working to develop
minimum common indicators to assess and compare quality of care across
different countries. The existence of a national adverse event reporting system
for traditional medicine products and services may also be considered as part of
qualitative indicators in traditional medicine.
• Efficiency indicators. The current monitoring framework includes indicators
for bed occupancy rate and for average length of stay (ALOS) of inpatients (all
hospitals). Waiting times and a composite index for efficiency may also be
considered. Health-care expenditures, for example, dollars spent as the principal
input, may be prioritized. They could then be correlated with health system
output measures, such as potential years of life lost. The iterative process of
developing health system efficiency measures and demonstrating their potential
uses should not be deferred or slowed down while waiting for the “perfect data”
to be collected.
Hepatitis treatment • Health service The proportion of persons with hepatatis B virus (HBV) infection who are currently
and care coverage receiving treatment and forecasts of the number of people that require treatment,
and the cost of treatment. The number of persons with chronic HBV infection may
be obtained from programme records, but the information may be incomplete or
difficult to obtain due to varying health system capacities, for example, lack of a
centralized treatment programme. Additional data on treatment courses offered in
the country by pharmaceutical companies and pharmacies would help in validating
data on treatment coverage.65
64
Regional framework for action on community-based rehabilitation: 2010–2020. Manila: WHO Regional Office for the Western Pacific; 2010
(http://iris.wpro.who.int/bitstream/handle/10665.1/6761/9789290614821_eng.pdf?sequence=1; accessed 22 August 2017).
65
Monitoring and evaluation for viral hepatitis B and C: recommended indicators and framework. Technical report. Geneva: World Health
Organization; 2016 (http://apps.who.int/iris/bitstream/10665/204790/1/9789241510288_eng.pdf; accessed 22 August 2017).
64
APPENDICES
Focus area Indicator domain Details

Information and • Resources and Measures of information communication technology (ICT) to facilitate cross-country
communication infrastructure data collection, comparisons and learning on the availability and use of health ICT.66
technologies This is one measure of health system inputs.
Mental health care • Mortality Most information systems do not include mental health conditions and their impact
• Health service on overall mental health outcomes. The need for surveillance for specific disorders
coverage varies from country to country, but basic data gathering is needed in all countries.67
• Resources and The complete recording of suicide deaths in death-registration systems requires
infrastructure good linkages with coronial and police systems, but can be impeded by stigma, and
by delay in determining the cause of death. Country health information systems
do not routinely collect data on a core set of mental health indicators, and cannot
provide reliable information on service coverage. Global indicators are currently
being developed. The introduction of Mental Health Law in countries such as the Lao
People’s Democratic Republic may help incentivize improved data collection.
Palliative care • Mortality The WHO Western Pacific, European and South-East Asia regions contain almost
three fourths of adults in need of end-of-life palliative care. Currently, mortality data
from diseases requiring palliative care are adjusted by the estimated pain prevalence
for each disease category.68
Patient experience and • Responsiveness The WHO Regional Offices for the Western Pacific and South-East Asia have jointly
people-centred health and people- developed a policy framework for people-centred health care. The framework
care centredness includes indicators for performance within and across the four domains of policy
action identified in the framework: individuals, families and communities; health
practitioners; health-care organizations; and health systems.
Quality in long-term • Quality and With ageing populations and growing costs, ensuring the quality of long-term care
care safety services has become an important policy priority for many countries in the Region.69
Measurement may be aligned with models of service delivery and integrated care.
Subjective well-being • Life expectancy Subjective well-being is defined as a good mental state, taking account of all the
and well-being various evaluations, positive and negative, that people make of their lives, and the
affective reactions of people to their experience. Like all self-reported measures,
survey-based measures of subjective well-being are sensitive to measurement
methodology. For reporting, a consistent measurement approach will need to be
adopted across all survey instruments and countries where possible, to limit the
additional variance potentially introduced by differing approaches.70
Violence and injury • Resources and Access to complete and quality epidemiologic data is a major driver for national
prevention infrastructure action for violence and injury prevention and a major responsibility for ministries
of health. Despite this, information systems in many Member States remain
underdeveloped. Where available, data may not currently be routinely disseminated
or used for scaling up preventive action.71
66
OECD. Draft OECD guide to measuring ICT in the health sector. Paris: Organisation for Economic Co-operation and Development; 2013 (http://
www.oecd.org/health/health-systems/Draft-oecd-guide-to-measuring-icts-in-the-health-sector.pdf; accessed 22 August 2017).
67
Regional Agenda for Implementing the Mental Health Action Plan 2013–2020 in the Western Pacific. Towards a social movement for
action on mental health and well-being. Manila: WHO Regional Office for the Western Pacific; 2015 (http://iris.wpro.who.int/bitstream/
handle/10665.1/10893/9789290617020_eng.pdf; accessed 22 August 2017).
68
Worldwide Palliative Care Alliance. Global atlas of palliative care at the end of life. Geneva: World Health Organization and WPCA; 2014 (http://
www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf; accessed 22 August 2017).
69
OECD. A good life in old age? Monitoring and improving quality in long-term care. Organisation for Economic Co-operation and Development;
2013 (http://www.oecd.org/health/health-systems/a-good-life-in-old-age-9789264194564-en.htm; accessed 22 August 2017).
70
OECD. Guidelines on measuring subjective well-being. Paris: Organisation for Economic Co-operation and Development; 2013 (http://www.
oecd.org/statistics/oecd-guidelines-on-measuring-subjective-well-being-9789264191655-en.htm; accessed 22 August 2017).
71
WHO Regional Committee on the Western Pacific Resolution WPR/RC66/7 on Violence and Injury Prevention. Manila: WHO Regional Office for
the Western Pacific Region; 2015 (http://www.wpro.who.int/about/regional_committee/66/documents/wpr_rc66_07_violence_and_injury_
prevention.pdf; accessed 22 August 2017).
65
Appendix 7. Long-term data opportunities

Approach Details
Big data “Big data” refers to large volumes of complex and variable data that require advanced techniques and technologies
for capture, storage, distribution, management and analysis.72 Big data include clinical data from clinical decision
support systems (physicians’ written notes and prescriptions, medical imaging, laboratory, pharmacy, insurance, and
other administrative data); patient data in electronic health records (EHRs), machine- or sensor-generated data, such
as from monitoring vital signs; social media posts, including Twitter feeds, status updates on Facebook and other
platforms, and web pages; and less patient-specific information, including emergency care data, news feeds, and
articles in medical journals.
Big data can provide new and consistent sources and methodologies to integrate multiple “location-based” variables
in order to support and inform official statistics and the indicators for the SDGs. Geography and location data enable
a richer picture of countries and their spatial subunits, and what is happening in and across them.
At a population level, traditional health data include information from vital statistics registries and hospital
admission statistics. The benefit of big data in health care lies in combining traditional and new forms of data, at
both the individual and population levels.73 Big data approaches may be able to manage the increasing quantity of
data needed to support SDG monitoring, including equity analysis.
Although the use of big data in low- and middle-income countries is challenging, it offers great potential rewards.
Most countries have separate vertical programmes for control of HIV, tuberculosis, malaria and other infections. Each
programme requires detailed information to be collected by community health workers. There is often a mismatch
between the information needs of the programme and the capacity of the associated field personnel to collect data
of sufficient quality for reporting, tracking and learning. The advent of electronic tools is now circumventing some of
the logistic and quality issues in data collection.74 Community health workers can use mobile phones, tablets and
computers for patient care and programme statistics.
Optimizing the application of big data involves more than confidentiality safeguards and minimum standards. A
broad effort to establish interoperability standards is imperative to maximize the benefits of big data. Currently,
some subgroups may not be included in data collection and analysis due to the multivariate nature of the data.
Geospatial Geospatial analysis is the application of statistical and other analytic techniques to geographical data. The need for
data and geospatial information systems (GIS) in sustainable development processes is evident. This information can describe
technologies where people are and their spatial relationships, which will help governments to develop goals and plans, and to
measure and monitor outcomes.
The literature suggests that geospatial information can assist in overcoming the aforementioned data challenges
and in strengthening the capability of governments and agencies to analyse and report on the SDGs. In fact,
the final 2015 MDG Report notes the need for geospatial information and suggests that geospatial data can help
monitor many aspects of development.75 In the Future We Want report, the UN emphasized the importance of using
geospatial technology to drive sustainable development and to support evidence-based policy-making.76
GIS is an essential tool to ensure that disease control programmes effectively target the relevant population groups.
For communicable disease control, GIS can strengthen surveillance and the outbreak response. For example, to
achieve malaria elimination, staff in national malaria programmes must know the location of malaria cases and
whether they have adequate access to testing, treatment and follow-up services. In an emergency, GIS can provide
a common operational picture to all stakeholders involved in the response, for a more coordinated, targeted
intervention. Visualization on a map of the services and populations affected helps decision-makers.
72
Raghupathi W, Raghupathi V. Big data analytics in healthcare: promise and potential. Health Inf Sci Syst. 2014;2:3. doi: 10.1186/2047-2501-2-3.
73
Wyber R, Vaillancourt S, Perry W, Mannava P, Folarnmi T, Celi LA. Big data in global health: improving health in low- and middle-income
countries. Bull World Health Organ. 2015;93(3):203–8. doi: 10.2471/BLT.14.139022.
74
Avilés W, Ortega O, Kuan G, Coloma J, Harris E. Quantitative assessment of the benefits of specific information technologies applied to clinical
studies in developing countries. Am J Trop Med Hyg. 2008;78(2):311–5. PMID: 18256435.
75
The Millennium Development Goals Report 2015. New York: United Nations; 2015 (http://www.un.org/millenniumgoals/2015_MDG_Report/
pdf/MDG%202015%20rev%20(July%201).pdf; accessed 22 August 2017).
76
UN System Task Team on the Post-2015 UN Development Agenda. Realizing the Future We Want for All: Report to the Secretary-General. New
York: United Nations; 2012 (http://www.un.org/millenniumgoals/pdf/Post_2015_UNTTreport.pdf; accessed 22 August 2017).
66
APPENDICES
Approach Details
Geospatial There are numerous examples of the use of these capabilities in Asia and the Pacific, including assessing barriers
data and to access for maternity services in the Philippines;77 mapping the distribution of women of childbearing age,
technologies pregnancies and births in Bangladesh;78 and generating scale-up scenarios in Cambodia and the Lao People’s
Democratic Republic.79 GIS has been used in several countries, including the People’s Republic of China, the Lao
People’s Democratic Republic, Solomon Islands and Vanuatu, to show the distribution of malaria risk, to guide
development of elimination strategies, and to monitor interventions.80
Geospatial information is especially valuable in measurement, monitoring and tracking processes for the SDGs.
Countries are encouraged to review their indicators and metadata through a “geographic location” lens and to
identify geospatial data gaps, as well as methodological issues (e.g. provide granularity and disaggregation of
indicators where appropriate). However, despite the importance of geospatial information and technologies in
SDG measurement and monitoring, there are few studies that specify the types of geospatial information and
technologies needed or how they should be provided.
At the Asia eHealth Information Network (AeHIN) fourth General Meeting in October 2015 an agreement was made
with Esri, a leading GIS software company, to establish an AeHIN GIS laboratory. Under the agreement, AeHIN
members and ministries of health will have free access to Esri’s ArcGIS technology for one year. The AeHIN GIS
laboratory’s remit is to enable countries to: (i) learn to embed GIS technology into good data management practices;
and (ii) receive support to geo-enable their health information system.81
Sources of As recommended by the IEAG-SDG on the data revolution, we should harness the richness of both traditional and
information new data, and work with “think-tanks, academics and NGOs as well as the whole UN family in analyzing, producing,
from other verifying and auditing data, providing a place for experimentation with methods for integrating different data
sectors sources, including qualitative data, perceptions data and citizen-generated data, and eventually produce a “people’s
baseline” for new goals.”82 Information sources from other sectors, such as commercial datasets on alcohol and
tobacco use, and pharmaceutical data on HBV vaccines, should be considered along with existing health data sources
(e.g. civil and vital registries, health insurance data, medical records and immunization registers).
A high-level panel to advise the global development agenda has emphasized the need to improve the quality of
information available to citizens and has called for a data revolution for sustainable development.83 In any country,
measuring progress will depend on the availability of and access to national fundamental data themes and to spatial
data infrastructure that reliably collects, integrates, analyzes, models, fuses and aggregates data for dissemination
and decision-making.
77
Dayrit MM, Ramirez CMO, Asuncion W, Ebener S, Bernardo C, Liwanag HJ, et al. Assessing Access to Prenatal, Delivery and Postpartum Services
in the Eastern Visayas Region, Philippines. Final technical report to WHO Philippines. Manila: Regional Office for the Western Pacific; 2015.
78
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67

Sustainable Development Goals and Universal Health Coverage

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Sustainable Development Goals and Universal Health Coverage

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What is the document about?

What is the document about?

What are some of the challenges mentioned in measuring progress?

What are some of the challenges mentioned in measuring progress?

SUSTAINABLE DEVELOPMENT GOALS

AND UNIVERSAL HEALTH COVERAGE

ISBN 978 92 9061 837 9

Shin Young-soo, MD, Ph.D.

yy limited data availability

Structure of the report

MDGs and SDGs

3.1 Methods and framework development

Indicator selection process

Figure 1. SDG and UHC Regional Monitoring Framework

MULTIPLE POPULATION GROUPS (EQUITY-FOCUSED MONITORING)

DETERMINANTS OF HEALTH Are these factors contributing to good health?

UNIVERSAL HEALTH COVERAGE Are all people accessing needed services

3.2 Monitoring domains

1. Health impact through the life course

3.3 Monitoring indicators

Figure 2. Guiding questions to support countries in SDG and UHC monitoring

3. How can countries

1. How can countries adapt

1. problem definition or redefinition

Figure 3. Opportunities to incorporate monitoring data into policy- and decision-making

Equity analysis and monitoring

From data to policy

Figure 4. Monitoring process (as a data-to-policy continuum)

SUSTAINABLE DEVELOPMENT GOALS (SDGs)

Data Transformation Indicator Selection Comparative Data,

Metadata (global, local)

Country options: Need for ongoing linkage and

Methods and analysis to support SDG and UHC monitoring

Table 2. Methods and analysis to support SDG and UHC monitoring

Box 1 What is a logic model?

Planned activities and interventions Expected results

Figure 5. Western Pacific Region logic model

INPUTS AND PROCESSES OUTPUTS

• Food and nutrition centredness

E R SE HEALTH SERVICE LIFESTYLE FACTORS

INPUTS AND PROCESSES OUTPUTS

Equity-focused service delivery:

Disaggregated by age, sex,

• Children <5 wasted

INPUTS AND PROCESSES OUTPUTS

• Availability of essential medicines Equity-focused service delivery:

EC TOR • Hospital average length of stay

S MUNIT For malaria patients

and Interventions target

malaria in poor rural areas Disaggregated by age, sex,

Disaggregated by age, sex,

4.3 How can countries conduct equity analysis and monitoring?

yy Demographic: age, sex

Figure 8. Hypothetical example of equity-focused analysis

Rural poor Rural non-poor Rural poor Rural non-poor

Outputs and Impacts:

Rural poor Rural non-poor Rural poor Rural non-poor

Human rights-based analysis (or HRBA analysis)25

The UN Statement of Common Understanding on Human Rights-Based Approaches to Development