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Assessing the coverage gap and the access deficit

Updated by Xenia Scheil-Adlung on 12.06.2015

Coverage refers to a broad concept that specifies the number of residents in a country that can access an essential benefit package of adequate quality if in equal need.

It is useful to distinguish between various dimensions of coverage with a view to effective access to health services. Population coverage describes rights and formal entitlements whereas effective access involves the provision of services and their use.

When measuring coverage, the indicators should be applied in a framework of country groups that reflect national challenges in achieving universal coverage. This is not the case if countries are grouped merely by income levels. The ILO suggests comparing countries by socio-economic development.

In the context of coverage, the two most relevant socio-economic indicators are: 

  • the extent of poverty, and
  • the extent of the informal economy.

Both represent common challenges that most developing countries face when striving towards universal coverage since they impact on the availability of domestic resources and reflect difficulties in reaching out to people that are not registered, work in rural areas or are poor.


Effective access is based on:

  • Population coverage by law
  • The physical availability of health care, health infrastructure, work force, medical goods and products, and timely provision of services 
  • Affordability of services is defined as the absence of financial barriers to needed health care aiming at avoiding health-related poverty or impoverishment. It refers to the maximum share of expenditure of total household income net of the cost of subsistence. Affordability of services for individuals or households differs from fiscal affordability
  • Financial protection includes minimizing out-of-pocket payments and compensation for productivity loss due to illness. Financial protection addresses the risk of impoverishment due to catastrophic health events, out-of-pocket payments, transport costs to reach health care facilities particularly in rural areas. 
  • The utilization and therefore access are influenced by the quality of services provided which is strongly correlated to the availability of sufficient resources and the level of public funding per capita. 

The ILO recommends using national surveys when available to measuring coverage and access gaps. When information contained in national surveys is not sufficient, the following indicators are useful:

Population coverage

Deficit of population coverage in percent of the population based on data from the ILO Social Health Protection database


The ILO Access Deficit Indicator estimates the dimension of availability of health services based on the availability of health professionals as a proxy (WHO Global Health Observatory, Health systems:Health workforce). It uses the relative difference between the national density of health professionals and the median value in the low vulnerability group of countries as a benchmark for developing countries.

Affordability and financial protection

Share of out-of-pocket payments in percent of total health care expenditures and Catastrophic health expenditure as share of total health expenditure based on National Health Account data. (WHO Global Health Observatory, Health systems:health financing).


Deficit in health spending per capita (in comparison to the median of the country group of similarly vulnerable countries) and maternal mortality ratio based on National health accounts. - (WHO Global Health Observatory, Health systems:health financing; and Equity:Women and health:Maternal maternal ratio).

Access and basic financial protection is necessary for all people, regardless of individual income level. Additionally, certain populations – the poor, women, elderly, disabled – are particularly vulnerable to catastrophic loss of income due to their health needs and needs dedicated protection and should be especially considered in an access coverage map.

Where applicable and feasible, the plan could go into further detail than outlined below, covering aspects such as gender or ethnic groups, if such data is available.

Health care coverage and access map specimen


The above map represents quantitative data that should be collected to inform social health protection plans.  Qualitative information to collect for the given populations include:

  • SPF objective
  • Description of existing provision
  • What elements define the coverage gaps
  • Strategies to overcome the barriers to coverage and access
  • Foreseen challenges to implementation and uptake
  • Recommendations
  • Costing scenarios

Both a quantitative and qualitative review could be conducted annually for evaluative and redesign purposes, all with the intent of progress on coverage overall and a reduction of inequities between population groups.

Recommended resource: New approaches to measuring deficits in social health protection coverage in vulnerable countries