District-level monitoring of universal health coverage, India.

Objective: To develop a framework and index for measuring universal health coverage (UHC) at the district level in India and to assess progress towards UHC in the districts.

Methods: We adapted the framework of the World Health Organization and World Bank to develop a district-level UHC index (UHC _d ). We used routinely collected health survey and programme data in India to calculate UHC _d for 687 districts from geometric means of 24 tracer indicators in five tracer domains: reproductive, maternal, newborn and child health; infectious diseases; noncommunicable diseases; service capacity and access; and financial risk protection. UHC _d is on a scale of 0% to 100%, with higher scores indicating better performance. We also assessed the degree of inequality within districts using a subset of 14 tracer indicators. The disadvantaged subgroups were based on four inequality dimensions: wealth quintile, urban-rural location, religion and social group.

Findings: The median UHC _d was 43.9% (range: 26.4 to 69.4). Substantial geographical differences existed, with districts in southern states having higher UHC _d than elsewhere in India. Service coverage indicator levels were greater than 60%, except for noncommunicable diseases and for service capacity and access. Health insurance coverage was limited, with about 10% of the population facing catastrophic and impoverishing health expenditure. Substantial wealth-based disparities in UHC were seen within districts.

Conclusion: Our study shows that UHC can be measured at the local level and can help national and subnational government develop prioritization frameworks by identifying health-care delivery and geographic hotspots where limited progress towards UHC is being made.