The WHO Global Reference List of 100 Core Health Indicators The WHO Global Reference List of 100 Core Health Indicators is a critical tool developed by the World Health Organization (WHO) and its partners to standardize and harmonize the measurement of health progress worldwide. It provides a concise, prioritized set of indicators necessary for monitoring a country's health situation, trends, and responses at both national and global levels. Purpose and Significance The primary objective of the Global Reference List is to serve as a normative guidance for the selection of standard health indicators and their definitions. This standardization is vital for several reasons: Global Monitoring: It facilitates consistent tracking of global health priorities, including progress toward the Sustainable Development Goals (SDGs) , particularly those related to health (SDG 3) and health-related targets in other goals. Reduced Reporting Burden: By establishing a common, prioritized set, ...
The WHO Global Reference List of 100 Core Health Indicators
The WHO Global Reference List of 100 Core Health Indicators is a critical tool developed by the World Health Organization (WHO) and its partners to standardize and harmonize the measurement of health progress worldwide. It provides a concise, prioritized set of indicators necessary for monitoring a country's health situation, trends, and responses at both national and global levels.
Purpose and Significance
The primary objective of the Global Reference List is to serve as a normative guidance for the selection of standard health indicators and their definitions. This standardization is vital for several reasons:
Global Monitoring: It facilitates consistent tracking of global health priorities, including progress toward the Sustainable Development Goals (SDGs), particularly those related to health (SDG 3) and health-related targets in other goals.
Reduced Reporting Burden: By establishing a common, prioritized set, it aims to rationalize and reduce the numerous, often duplicative, reporting requirements placed on countries by various global partners.
Improved Alignment and Investment: The list promotes greater alignment of domestic and external investments into a country’s data systems and analytical capacity, fostering a single, country-led health sector platform for results.
National Guidance: It guides countries in selecting priority indicators for their national health sector plans, strategies, and monitoring efforts at both national and sub-national levels.
The WHO Global Reference List of 100 Core Health Indicators is structured around four main domains that cover the full spectrum of global health priorities.
| Domain | Description and Focus | Example Subdomains / Key Topics |
| 1. Health Status | Measures the overall health of the population, including mortality, morbidity, and fertility. | Mortality by age, sex, and cause; Morbidity (disease burden); Fertility and reproductive health outcomes. |
| 2. Risk Factors | Indicators that monitor the prevalence of health-related risks, including behavioral, environmental, and metabolic factors. | Nutrition; Infections; Environmental risks (e.g., water, sanitation, air pollution); Non-communicable disease (NCD) risks (e.g., tobacco, alcohol, physical activity); Injuries and violence. |
| 3. Service Coverage | Tracks the extent to which the population receives essential health services, reflecting access and uptake. | Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH); Immunization; HIV, TB, and Malaria; Neglected Tropical Diseases (NTDs); Non-communicable Diseases (NCDs) interventions. |
| 4. Health Systems | Evaluates the inputs, processes, and outputs of the health system that enable service delivery and overall health improvement. | Health workforce; Health financing; Health information systems; Access to essential medicines and technologies; Governance and capacity. |
Context
The Global Reference List of 100 Core Health Indicators was developed by the World Health Organization (WHO) and partners to provide a standard set of indicators for monitoring national and global health progress, particularly in relation to the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC). The four-domain structure ensures a comprehensive view of the health situation, covering not only the health outcomes but also the factors that influence them and the performance of the health system itself.
Structure and Domains
The 100 core indicators are organized across four main domains to capture a comprehensive view of a country's health landscape:
1. Health Status
This domain focuses on indicators related to disease and death, including key measures of health outcomes.
Examples: Life expectancy at birth, mortality rates (e.g., under-five mortality, maternal mortality ratio, mortality from specific diseases like TB, AIDS, and non-communicable diseases), and total fertility rate.
2. Risk Factors
This area tracks key determinants of health, including environmental, behavioral, and nutritional factors that influence disease and injury.
Examples: Indicators related to nutrition (e.g., prevalence of stunting, wasting), environmental factors, tobacco and alcohol use, physical activity, injuries, and violence.
3. Service Coverage
This domain measures the extent to which essential health services—from prevention and promotion to treatment and rehabilitation—reach the population.
Examples: Coverage for essential services like immunization, antenatal care, skilled birth attendance, HIV treatment, contraception, and access to water and sanitation. This section is crucial for monitoring Universal Health Coverage (UHC).
4. Health Systems
These indicators assess the capacity and performance of the health system itself, including its resources and governance.
Examples: Health workforce density, total health expenditure as a percentage of GDP, domestic general government health expenditure, and indicators related to health information systems.
Evolution and the SDGs
The Global Reference List has been periodically updated to reflect evolving public health priorities. The 2018 edition was a significant revision, incorporating indicators to align with the Sustainable Development Goals (SDGs), particularly emphasizing Universal Health Coverage (UHC) and the growing importance of non-communicable diseases (NCDs) and environmental risk factors.
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The WHO Global Reference List: Health Status Indicators
The Health Status domain is the foundational component of the WHO Global Reference List of 100 Core Health Indicators. This set of indicators provides a concise, quantitative picture of a population's overall health and well-being by measuring the direct outcomes of health system performance, disease prevalence, and environmental factors.
It focuses on measuring health achievements and failures, primarily through mortality, morbidity (disease), and fertility statistics. These core metrics are essential for tracking progress toward the health targets of the Sustainable Development Goals (SDGs), especially SDG 3, which aims to ensure healthy lives and promote well-being for all at all ages.
Health Status Indicator
The first domain of the WHO Global Reference List of 100 Core Health Indicators is Health Status. This domain focuses on direct measures of health outcomes, particularly mortality, morbidity, and fertility.
Based on the latest comprehensive versions of the list (which incorporate the Sustainable Development Goals or SDGs), the key indicators within this domain are organized as follows:
Mortality Indicators 💀
| Indicator | Metric |
| Life expectancy at birth | Years |
| Healthy life expectancy at birth | Years |
| Under-five mortality rate | Deaths per 1,000 live births |
| Infant mortality rate | Deaths per 1,000 live births |
| Neonatal mortality rate | Deaths per 1,000 live births |
| Maternal mortality ratio | Deaths per 100,000 live births |
| Adult mortality rate | Probability of dying between 15 and 60 years per 1,000 population |
| Suicide rate | Deaths per 100,000 population |
| Mortality rate due to road traffic injuries | Deaths per 100,000 population |
| Age-standardized mortality rate from non-communicable diseases (NCDs) | Probability of dying between age 30 and 70 from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases |
| TB mortality rate | Deaths per 100,000 population (excluding HIV) |
| AIDS-related mortality rate | Deaths per 100,000 population (for all ages) |
| Malaria mortality rate | Deaths per 100,000 population at risk |
| Homicide rate | Deaths per 100,000 population |
Morbidity & Disability Indicators 🤕
| Indicator | Metric |
| Incidence of HIV | New infections per 1,000 uninfected population |
| Incidence of tuberculosis | New and relapse cases per 100,000 population |
| Malaria incidence | New cases per 1,000 population at risk |
| Hepatitis B surface antigen prevalence | Percentage of children under 5 years |
| Reported number of people requiring interventions against neglected tropical diseases | Number of people |
| Disability-Adjusted Life Years (DALYs) | Rate per 100,000 population |
Fertility Indicators 🤰
| Indicator | Metric |
| Total fertility rate | Births per woman |
| Adolescent birth rate | Births per 1,000 women aged 15-19 years |
Note: The WHO Global Reference List of 100 Core Health Indicators (2018 revision is the last major publication) provides the standard set of core indicators prioritized for global monitoring, aligning with the health-related Sustainable Development Goals (SDGs).
Key Categories of Health Status Indicators
The Health Status domain is characterized by several critical measurements that monitor a population's health from birth to old age:
1. Mortality and Longevity
These indicators reflect the number of deaths in a population and the overall life expectancy, serving as the most basic measures of a country's health and development.
| Indicator | Description | Significance |
| Life expectancy at birth | The average number of years a newborn is expected to live if current mortality patterns remain unchanged. | A key measure of overall population health and longevity. |
| Under-five mortality rate | The probability of a child born in a specific year or period dying before reaching the age of five (per 1,000 live births). | Highly sensitive to a country's health and socio-economic conditions, and a primary indicator for child health. |
| Maternal mortality ratio | The number of maternal deaths (deaths due to complications from pregnancy or childbirth) per 100,000 live births. | A key measure of the quality and access to maternal health care services. |
| Adult mortality rate | The probability of dying between the ages of 15 and 60 years. | Reflects non-communicable diseases, injuries, and health system effectiveness for the working-age population. |
2. Cause-Specific Mortality
To address the global burden of disease, the list includes indicators that track deaths from major health threats, allowing for targeted public health interventions.
Mortality from Non-Communicable Diseases (NCDs): This tracks premature mortality (death between ages 30 and 70) from the four main NCDs: cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases. This is a primary target of SDG 3.
Mortality from Communicable Diseases: This includes specific mortality rates for diseases of global concern, such as Tuberculosis (TB) and AIDS-related mortality rate.
3. Fertility and Reproductive Health
These indicators measure key demographic and reproductive outcomes that directly impact population health and planning.
Total Fertility Rate (TFR): The average number of children that would be born to a woman over her lifetime.
Adolescent birth rate: The annual number of births to women aged 15-19 per 1,000 women in that age group. This is a critical marker for adolescent health and development.
4. Morbidity and Disability
These measures look beyond death to quantify the burden of illness and disability within the population.
Incidence/Prevalence of Major Diseases: While some specific rates fall under the service coverage domain (e.g., HIV incidence), the overall focus here is on the extent of ill-health, including tracking the prevalence of certain conditions or health challenges.
Disability-Adjusted Life Years (DALY): Although not explicitly one of the 100 core indicators, related concepts of disability and disease burden underpin this domain, often measured through life expectancy adjusted for years lost due to disability (HALE).
Data for Action
The Health Status indicators rely on robust national data systems, particularly Civil Registration and Vital Statistics (CRVS), which record all births and deaths. The standardization provided by the WHO's list is intended to prompt countries to invest in these systems, ensuring high-quality, disaggregated data that accurately reflects the health outcomes of all population groups. By consistently monitoring these core health status indicators, countries and the global community can measure the impact of health policies and prioritize resources to close health gaps.
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The WHO Global Reference List: Risk Factors for Health
The Risk Factors domain of the WHO Global Reference List of 100 Core Health Indicators is crucial for public health planning. Unlike the Health Status domain, which measures outcomes (sickness and death), the Risk Factors domain measures the determinants—the exposures, behaviors, and environmental conditions—that influence health outcomes.
Monitoring these indicators allows countries to implement preventative strategies, shift focus from treatment to prevention, and address the underlying drivers of the leading causes of morbidity and mortality, particularly for Non-Communicable Diseases (NCDs) and infectious diseases.
Risk Factors Indicator
The second domain of this list is Risk Factors. The indicators within this domain are typically grouped into subdomains: Nutrition, Environmental risk factors, Behavioural risk factors, and Injuries and violence.
Here are the indicators for the second domain, Risk Factors, from the 2018 Global Reference List:
Domain 2: Risk Factors
| Subdomain | Indicator Name |
| Nutrition | 1. Prevalence of stunting in children under 5 years of age |
| 2. Prevalence of wasting in children under 5 years of age | |
| 3. Prevalence of overweight in children under 5 years of age | |
| 4. Prevalence of overweight in adults (18+ years) | |
| 5. Prevalence of anaemia in women of reproductive age (15–49 years) | |
| 6. Exclusive breastfeeding rate for infants aged 0–5 months | |
| Environmental | 7. Proportion of population using safely managed drinking water services |
| 8. Proportion of population using safely managed sanitation services | |
| 9. Proportion of population with primary reliance on clean fuels and technology | |
| 10. Mortality rate attributed to household and ambient air pollution | |
| 11. Mortality rate attributed to unsafe water, unsafe sanitation and lack of hygiene | |
| Behavioural | 12. Prevalence of current tobacco use in persons 15+ years of age |
| 13. Total alcohol per capita (15+ years) consumption | |
| 14. Prevalence of insufficient physical activity in adults (18+ years) | |
| 15. Prevalence of raised blood pressure (age-standardized) | |
| 16. Prevalence of raised blood glucose/diabetes (age-standardized) | |
| 17. Prevalence of obesity in adults (18+ years) | |
| Injuries and violence | 18. Mortality rate from road traffic injuries |
| 19. Mortality rate from suicide |
Note: The indicators listed above are based on the structure of the WHO's 2018 Global Reference List. The total number of core indicators in the full list is 100, distributed across four domains.
Key Categories of Risk Factor Indicators
The Risk Factors domain is broadly categorized to capture the full spectrum of influences on population health: Behavioral, Metabolic, Nutritional, Environmental, and those related to Injuries and Violence.
1. Behavioral Risk Factors
These are modifiable choices and habits that significantly contribute to the global burden of disease, especially NCDs. They are primary targets for health education and policy interventions.
| Indicator | Focus Area | Significance |
| Tobacco use | Prevalence of current tobacco use among adults (aged 15+ or 18+). | The single most preventable cause of death globally. |
| Harmful use of alcohol | Total alcohol per capita (age 15+ years) consumption. | A measure of exposure to a major risk for liver disease, cancers, injuries, and violence. |
| Insufficient physical activity | Prevalence of insufficient physical activity among adults (and adolescents). | A key driver of obesity, cardiovascular disease, and diabetes. |
| Unsafe sexual behavior | Condom use at last high-risk sexual encounter. | Essential for monitoring the transmission of HIV and other Sexually Transmitted Infections (STIs). |
2. Metabolic and Nutritional Risk Factors
These indicators reflect diet-related risks and their physiological consequences, which are central to the rise of NCDs worldwide.
| Indicator | Focus Area | Significance |
| Overweight and obesity | Prevalence of overweight and obesity in adults and adolescents, and children under 5 years of age. | A major risk factor for diabetes, heart disease, and some cancers. |
| Raised physiological measures | Prevalence of raised blood pressure (hypertension) and raised blood glucose (diabetes/pre-diabetes) in adults. | Key metabolic changes that directly lead to cardiovascular diseases. |
| Nutritional status (Children) | Prevalence of stunting (low height-for-age) and wasting (low weight-for-height) in children under 5. | Critical indicators of chronic and acute undernutrition. |
| Early and Exclusive Breastfeeding | Exclusive breastfeeding rate for children under 6 months. | A protective factor for child health, immune development, and reduced risk of infectious diseases. |
3. Environmental and Occupational Risk Factors
The physical environment is a major determinant of health, tracked by indicators related to critical resources and pollution.
Water and Sanitation: Percentage of the population using safely managed drinking-water services and safely managed sanitation services. These are fundamental to preventing diarrhoeal diseases and other infectious illnesses.
Air Pollution: Ambient (outdoor) air pollution levels in urban areas and the percentage of the population using clean fuels and technology for cooking/heating. Air pollution is a major contributor to respiratory and cardiovascular disease mortality.
Occupational Risk: Indicators related to occupational injuries or specific hazards, though often collected at the national level, underpin the monitoring of a safe working environment.
4. Violence and Injury-Related Risk
While actual deaths from injuries are in the Health Status domain, the risk of violence and injury is monitored here.
Road Traffic Injuries: Indicators tracking the frequency and severity of injuries, which helps inform road safety policy.
Intimate Partner Violence (IPV): Prevalence of women who have experienced physical and/or sexual violence by a current or former intimate partner. This is a critical public health and human rights issue.
The Role of Risk Factor Monitoring
The inclusion of these indicators in the WHO Global Reference List moves health monitoring upstream—from passively counting the sick and dead to actively tracking the causes of sickness and death. This shift has three key benefits:
Prioritization: It highlights the most urgent public health threats that require policy intervention (e.g., controlling tobacco or improving sanitation).
Prevention: It provides the evidence base for preventative programs, such as taxation on tobacco/alcohol, campaigns for physical activity, or regulating pollution standards.
Accountability: It allows national and global stakeholders to hold governments and institutions accountable for creating environments that promote health and reduce unnecessary exposure to harm.
This final domain of indicators highlights the importance of proactive, preventative health policy. By establishing a standard set of metrics for Risk Factors, the WHO Global Reference List empowers countries to effectively monitor the underlying causes of disease, shifting the global focus from merely reacting to illness to creating healthier environments and supporting healthier behaviors. This framework is vital for achieving the ambitious targets of the SDGs, ensuring that health gains are not only sustained but are protected from the threats posed by modern lifestyles and environmental hazards.
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The WHO Global Reference List: Service Coverage
The Service Coverage domain is one of the four main categories in the WHO Global Reference List of 100 Core Health Indicators. It serves as the primary gauge of a country's progress toward achieving Universal Health Coverage (UHC), which is enshrined in Sustainable Development Goal (SDG) 3.8.
These indicators do not measure the mere existence of a health service, but rather the proportion of the population needing a service who actually receive it. By tracking coverage across diverse health areas, this domain assesses the effectiveness and equity of the health system in delivering essential care.
Service Coverage Indicator
The WHO Global Reference List of 100 Core Health Indicators (2018 edition) includes 36 indicators in Domain 3: Service Coverage. These indicators span multiple sub-domains reflecting the spectrum of health services.
The Service Coverage indicators are structured into the following sub-domains:
3.1 Reproductive, Maternal, Newborn, Child, and Adolescent Health
| Indicator | Description |
| Antenatal care (ANC) coverage | Percentage of women aged 15-49 with a live birth who received at least four ANC visits. |
| Births attended by skilled health personnel | Percentage of live births attended by skilled health personnel. |
| Postnatal care (PNC) coverage | Percentage of women with a live birth who received PNC within two days of birth. |
| Contraceptive prevalence | Percentage of women aged 15-49 who are currently using any modern contraceptive method. |
| Unmet need for family planning | Percentage of women aged 15-49 who are fecund and sexually active but are not using any method of contraception and do not want to become pregnant or want to postpone their next birth. |
| Adolescent birth rate | Annual number of births to women aged 15-19 per 1,000 women in that age group. |
| Coverage of care-seeking for suspected pneumonia | Percentage of children aged 0-59 months with suspected pneumonia taken to an appropriate healthcare provider. |
| Pneumonia treatment coverage | Percentage of children aged 0-59 months with suspected pneumonia receiving antibiotics. |
| Diarrhoea treatment coverage | Percentage of children aged 0-59 months with diarrhoea receiving oral rehydration salts (ORS) and/or zinc. |
| Early initiation of breastfeeding | Percentage of children aged 0-23 months born in the last two years who were put to the breast within one hour of birth. |
| Exclusive breastfeeding under six months | Percentage of infants aged 0-5 months who are exclusively breastfed. |
| Immunization coverage | Coverage of Diphtheria-Tetanus-Pertussis (DTP3), Measles-containing vaccine second dose (MCV2), and Pneumococcal conjugate vaccine (PCV3). (3 separate indicators) |
3.2 Infectious Diseases
| Indicator | Description |
| HIV testing coverage | Percentage of adults and children with known HIV status. |
| Antiretroviral therapy (ART) coverage | Percentage of people living with HIV currently receiving ART. |
| Tuberculosis (TB) treatment coverage | TB cases detected and successfully treated. |
| TB preventive therapy coverage | Percentage of contacts of TB cases and people newly enrolled in HIV care who started TB preventive treatment. |
| Malaria insecticide-treated net (ITN) coverage | Percentage of the population at risk who slept under an ITN the previous night. |
| Malaria intermittent preventive treatment (IPTp) coverage | Percentage of pregnant women in endemic areas who received at least two doses of IPTp. |
| Neglected Tropical Diseases (NTD) coverage | Number of people requiring interventions against NTDs. (This indicator is typically broken down by specific NTDs, such as coverage of mass drug administration for Trachoma, Schistosomiasis, etc.) |
3.3 Non-communicable Diseases (NCDs)
| Indicator | Description |
| Cervical cancer screening coverage | Percentage of women aged 30-49 screened for cervical cancer in the past 5 years. |
| Hypertension treatment coverage | Percentage of adults (18+) with hypertension receiving treatment. |
| Diabetes treatment coverage | Percentage of adults (18+) with diabetes receiving treatment. |
| Alcohol consumption | Total (recorded and unrecorded) alcohol per capita (age 15+ years) consumption. |
| Tobacco use | Age-standardized prevalence of current tobacco use among people aged 15 years and older. |
| Physical activity | Prevalence of insufficient physical activity among adults (18+). |
| Salt/sodium intake | Mean population intake of salt (grams per day) per person. |
3.4 Service Capacity and Access
| Indicator | Description |
| Essential health services coverage (UHC service coverage index) | Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions). |
| Access to essential medicines | Percentage of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis. |
| Health workforce density and distribution | Density of human resources for health (doctors, nurses and midwives) per 1,000 population. |
| International Health Regulations (IHR) capacity | IHR (2005) State Party annual reporting scores (or other appropriate monitoring tool). |
| Availability of key health services in primary health care (PHC) facilities | Percentage of primary health care facilities with key health services available. |
| Access to improved sanitation facilities | Percentage of population using at least basic sanitation services. |
| Access to safely managed drinking water services | Percentage of population using safely managed drinking water services. |
| Death registration coverage | Percentage of deaths registered with a cause of death. |
Note: The Global Reference List aims to provide a standard set, and specific national implementation may vary. The Universal Health Coverage (UHC) service coverage index (3.8.1) aggregates several of the indicators listed above.
Key Categories of Service Coverage Indicators
The Service Coverage domain is structured to reflect the continuum of care, from health promotion and disease prevention to treatment for various conditions.
1. Reproductive, Maternal, Newborn, and Child Health (RMNCH)
These are fundamental indicators of a robust primary health care system, focusing on key life stages where interventions have the highest impact on survival.
| Indicator | Focus Area | Significance |
| Family Planning | Demand for family planning satisfied with modern methods. | Measures access to methods that prevent unintended pregnancies and promote maternal health. |
| Antenatal Care (ANC) | Antenatal care coverage (at least four visits, or the full recommended schedule). | Tracks the quality and frequency of care received during pregnancy to monitor maternal and fetal health. |
| Skilled Birth Attendance | Births attended by skilled health personnel. | A critical indicator for reducing maternal and newborn mortality. |
| Immunization Coverage | Coverage of Diphtheria, Tetanus, and Pertussis (DTP3) containing vaccine (or the UHC Service Coverage Index tracer vaccines). | A core measure of a country's success in protecting children from preventable infectious diseases. |
| Child Treatment | Care-seeking for symptoms of pneumonia (or other major childhood illnesses). | Measures access to appropriate treatment for the leading causes of child mortality. |
2. Infectious Diseases (Communicable Diseases)
These indicators track the success of specific programs aimed at controlling and eliminating major infectious disease epidemics.
| Indicator | Disease | Significance |
| HIV/AIDS | Adults and children living with HIV currently receiving antiretroviral therapy (ART). | Measures the effectiveness of the treatment program in managing the epidemic. |
| Tuberculosis (TB) | TB treatment coverage (or new and relapse TB cases detected and treated successfully). | Reflects the capacity of the health system to detect, treat, and control one of the oldest and deadliest diseases. |
| Malaria | Population at risk in malaria-endemic areas who slept under an insecticide-treated net (ITN). | A key measure of vector control and preventative intervention coverage. |
| Hepatitis B | Coverage of Hepatitis B (HepB) birth dose vaccination. | A core preventative measure against chronic liver disease and cancer. |
3. Non-Communicable Diseases (NCDs)
As NCDs become the leading cause of death globally, service coverage has expanded to include long-term chronic disease management.
Hypertension Treatment Coverage: Prevalence of treatment for hypertension among adults with the condition. This measures the health system's ability to manage a key metabolic risk factor.
Diabetes Treatment Coverage: A similar measure for the proportion of people with diabetes receiving treatment and care.
Cervical Cancer Screening: Coverage of screening for cervical cancer among women.
Tobacco Cessation Services: Provision of services to help people quit tobacco use.
4. Overall Service Capacity and Access
These indicators, often summarized in the Universal Health Coverage (UHC) Service Coverage Index, combine key tracer interventions to provide a single, composite score of national health service delivery. They include:
Service Capacity: Measures related to the availability of essential health system infrastructure, such as the number of hospital beds or density of qualified health personnel.
Geographic and Financial Access: While the primary Service Coverage indicators measure who gets the service, broader UHC monitoring also includes indicators of financial protection, such as the proportion of the population facing catastrophic or impoverishing health expenditure (covered in the Health Systems domain).
The Service Coverage Imperative
The Service Coverage domain is the bridge between policy and health outcomes. High service coverage, particularly when monitored for different socioeconomic and geographic groups, indicates an equitable and high-performing health system. Low or uneven coverage signals critical gaps, suggesting that a lack of access to care is leading directly to preventable sickness (morbidity) and death (mortality). Tracking these indicators is essential for governments to focus investments, strengthen health worker training, and ensure that the promise of health for all is delivered on the front lines of care.
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The WHO Global Reference List: Health Systems Indicators
The Health Systems domain is the fourth and final component of the WHO Global Reference List of 100 Core Health Indicators. This domain shifts the focus from population-level health outcomes (Health Status and Risk Factors) and service delivery (Service Coverage) to the inputs, structures, and processes that enable a health system to function and sustain performance.
These indicators are crucial for monitoring the administrative and resource backbone of Universal Health Coverage (UHC), ensuring that the system is equitable, efficient, and resilient. They provide the data needed to understand why certain services are or aren't reaching the population.
Health Systems Indicator
The indicators of the Fourth Domain of the WHO Global Reference List of 100 Core Health Indicators (2018 edition), separated by their structure (sub-domains).
Domain 4: Health Systems
The Fourth Domain is divided into the following four sub-domains:
1. Health expenditure and financing
| Indicator Number | Indicator Description |
| 86 | Total health expenditure per capita (US$) |
| 87 | Total health expenditure as percentage of Gross Domestic Product (GDP) (%) |
| 88 | General government expenditure on health as percentage of total health expenditure (%) |
| 89 | Out-of-pocket expenditure as percentage of total health expenditure (%) |
2. Health workforce
| Indicator Number | Indicator Description |
| 90 | Density of physicians (per 1000 population) |
| 91 | Density of nursing and midwifery personnel (per 1000 population) |
| 92 | Density of dentistry personnel (per 1000 population) |
| 93 | Density of pharmaceutical personnel (per 1000 population) |
| 94 | Density of other health workers (per 1000 population) |
3. Health information
| Indicator Number | Indicator Description |
| 95 | Completeness of birth registration (%) |
| 96 | Completeness of death registration (%) |
| 97 | Cause-of-death coverage (%) |
4. Essential medicines and health products
| Indicator Number | Indicator Description |
| 98 | Availability of selected essential medicines and health products in primary health care facilities (%) |
| 99 | Price ratio of selected generic medicines and health products |
| 100 | Affordability of selected essential generic medicines and health products (number of days' wages to purchase treatment) |
Key Pillars of the Health Systems Domain
The Health Systems domain is typically categorized into four main areas, reflecting the essential functions of a national health system: Health Finance, Health Workforce, Health Information, and Governance/Infrastructure.
1. Health Financing 💰
Financial indicators are vital for tracking progress toward the UHC goal of financial risk protection. They determine whether people can access the care they need without facing catastrophic financial hardship.
| Indicator | Focus Area | Significance |
| Total Health Expenditure (THE) as a % of GDP | Overall investment in health. | Measures a country's total commitment to health as a share of its economic output. |
| General Government Health Expenditure (GGHE) as a % of THE | Public funding share. | Tracks the government's relative contribution to health funding, which is key to equity. |
| Out-of-Pocket (OOP) Expenditure as a % of THE | Household financial burden. | The core indicator of financial risk protection. High OOP suggests a heavy, potentially impoverishing, burden on individuals. |
| Proportion of population with large household expenditure on health | Catastrophic spending. | Measures the percentage of people spending more than a defined threshold (e.g., 10% or 25%) of their household budget on health. |
2. Health Workforce 🧑⚕️
The quality and availability of the health workforce are direct determinants of service delivery. These indicators track the distribution and capacity of human resources.
| Indicator | Focus Area | Significance |
| Health Worker Density | Number of doctors, nurses, and midwives per 1,000 population. | A basic measure of capacity to provide essential services. |
| Distribution and Availability | Density of health workers by subnational area (where available). | Highlights geographic disparities and inequities in access to care. |
| Health Management Capacity | Presence of a national human resources for health strategy/plan. | Measures policy commitment to the recruitment, training, and retention of staff. |
3. Essential Medicines and Medical Products 💊
Ensuring that essential medicines, vaccines, and commodities are available is a prerequisite for effective service delivery.
| Indicator | Focus Area | Significance |
| Availability of essential medicines | Proportion of health facilities with a core set of essential medicines. | Measures the functionality of the supply chain and procurement systems. |
| Vaccine Stock Outs | Tracking the percentage of health facilities that experienced a stock-out of key vaccines (e.g., DTP) over a specified period. | A direct measure of supply chain reliability, particularly for routine immunization. |
4. Health Information Systems (HIS) and Governance 📊
These structural indicators focus on the system's ability to monitor itself and adhere to international standards for safety and security.
Birth and Death Registration Completeness: Percentage of live births and deaths registered in a civil registration system. This is the most fundamental indicator of a functional Health Information System (HIS), providing the baseline data for all demographic and health statistics.
International Health Regulations (IHR) Capacity: A country's core capacity to prevent, detect, and respond to public health emergencies. This is a measure of global health security and preparedness.
Availability of National Health Strategies: Existence of a multi-year national health sector strategy or plan.
Facility Access: Proportion of the population living within a defined distance or travel time of a functional primary health care facility.
The System's Reflection
The Health Systems domain represents the engine driving the entire health system. Without adequate and equitable financing, a well-trained workforce, a reliable supply of medicines, and the ability to accurately track births, deaths, and service use, a country cannot achieve or sustain meaningful improvements in health status or service coverage. The data from this domain is vital for policymakers to allocate resources effectively, reform spending practices, and ensure that the foundational elements of healthcare are strong enough to withstand the inevitable challenges of future health crises.
.jpg "The Foundation of Global Well-being: SDG 3 and its Interconnected Health Agenda")
The Foundation of Global Well-being: SDG 3 and its Interconnected Health Agenda
The 2030 Agenda for Sustainable Development, adopted by all United Nations Member States in 2015, established the 17 Sustainable Development Goals (SDGs) as a blueprint for peace and prosperity for people and the planet. At the heart of this comprehensive plan lies SDG 3: Good Health and Well-being, which serves as both a central goal in itself and a critical prerequisite for achieving every other SDG.
This section details the targets of the core health goal (SDG 3) and highlights the essential health-related targets embedded within other SDGs, demonstrating the deeply interconnected nature of global health and sustainable development.
Good Health and Well-being Indicator
The core Sustainable Development Goal (SDG) dedicated to health is SDG 3: Good Health and Well-being. However, because health is influenced by many factors, several targets in other SDGs are also highly relevant to the "health category."
1. Core Health Goal (SDG 3) Targets
Goal 3: Ensure healthy lives and promote well-being for all at all ages.
| SDG Target | Description |
| 3.1 | Reduce the global maternal mortality ratio to less than 70 per 100,000 live births. |
| 3.2 | End preventable deaths of newborns and children under 5 years of age. |
| 3.3 | End the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepat |
| 3.4 | Reduce by one-third premature mortality from non-communicable diseases (NCDs) and promote mental health and well-being. |
| 3.5 | Strengthen the prevention and treatment of substance abuse, including harmful use of alcohol. |
| 3.6 | Halve the number of global deaths and injuries from road traffic accidents (Target year was 2020). |
| 3.7 | Ensure universal access to sexual and reproductive health-care services (including family planning, information, and education). |
| 3.8 | Achieve universal health coverage (UHC), including financial risk protection and access to quality essential services, medicines, and vaccines. |
| 3.9 | Substantially reduce deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination. |
| 3.a | Strengthen the implementation of the WHO Framework Convention on Tobacco Control. |
| 3.b | Support research and development of vaccines/medicines and provide affordable access to essential medicines and vaccines. |
| 3.c | Substantially increase health financing and the recruitment, training, and retention of the health workforce in developing countries. |
| 3.d | Strengthen capacity for early warning, risk reduction, and management of national and global health risks. |
2. Health-Related Targets in Other SDGs
The following targets from other SDGs address major determinants of health or direct health outcomes.
| Related SDG | Target No. | Health-Related Focus |
| SDG 1: No Poverty | 1.3 | Implement social protection systems and measures for all, crucial for poor people to afford healthcare. |
| SDG 2: Zero Hunger | 2.2 | End all forms of malnutrition (stunting, wasting, overweight). |
| SDG 4: Quality Education | 4.7 | Ensure education promotes lifestyles for health and sustainable development. |
| SDG 5: Gender Equality | 5.2 | Eliminate all forms of violence against women and girls (a major public health concern). |
| SDG 6: Clean Water & Sanitation | 6.1 & 6.2 | Achieve universal access to safe drinking water, sanitation, and hygiene (WASH) to prevent infectious diseases. |
| SDG 8: Decent Work & Economic Growth | 8.8 | Promote safe and secure working environments for all workers (occupational health). |
| SDG 11: Sustainable Cities | 11.6 | Reduce the adverse environmental impact of cities, including by paying special attention to air quality. |
| SDG 13: Climate Action | 13.1 | Strengthen resilience and adaptive capacity to climate-related hazards and natural disasters (direct threats to human health). |
The Core Health Goal: SDG 3—Ensuring Healthy Lives for All
SDG 3 is ambitious, addressing the entire spectrum of global health challenges. It has thirteen specific targets that fall into three main categories: improving health outcomes, addressing risk factors, and strengthening health systems.
The core objective of SDG 3 is to tackle the unfinished agenda of preventable deaths while preparing for new global challenges. This means reducing the global maternal mortality ratio to less than 70 per 100,000 live births and ending preventable deaths of newborns and children under 5 years of age (Targets 3.1 and 3.2).
The goal also demands an end to the epidemics of major communicable diseases, specifically AIDS, tuberculosis, malaria, and neglected tropical diseases (Target 3.3). Simultaneously, it addresses the growing threat of Non-Communicable Diseases (NCDs), calling for a one-third reduction in premature mortality from NCDs and the promotion of mental health and well-being (Target 3.4).
Beyond diseases, SDG 3 focuses on crucial health risk factors, including strengthening the prevention and treatment of substance abuse (Target 3.5) and substantially reducing deaths and injuries from road traffic accidents (Target 3.6). Crucially, the goal mandates the provision of essential services, with Target 3.7 focusing on universal access to sexual and reproductive health-care services.
Systemic Health Pillars
The success of these clinical goals depends entirely on resilient and accessible health systems. Target 3.8, the aspiration for Universal Health Coverage (UHC), is perhaps the most encompassing: it aims to ensure all people obtain needed services without suffering financial hardship. The "means of implementation" targets complement this by calling for stronger implementation of the WHO Framework Convention on Tobacco Control (Target 3.a), greater support for R&D and affordable access to essential medicines and vaccines (Target 3.b), increased health financing and workforce capacity (Target 3.c), and robust capacity for early warning and risk management of global health risks (Target 3.d).
Health-Related Targets in Other SDGs: The Determinants of Health
Health is not simply the absence of disease; it is a product of social, economic, and environmental conditions. For this reason, numerous targets across the other sixteen SDGs are crucial determinants of health and well-being. Achieving SDG 3 is impossible without progress in these areas:
Poverty and Hunger (SDGs 1 & 2): Poverty prevents access to care and essential medicines. SDG 1's call for social protection systems is a critical financial shield for health. Equally vital is SDG 2's focus on ending all forms of malnutrition—malnourished children have weaker immune systems and suffer higher mortality rates.
WASH (SDG 6): Targets 6.1 and 6.2 call for universal access to safe drinking water, sanitation, and hygiene (WASH). These are the most effective public health interventions, directly preventing the spread of infectious and waterborne diseases like cholera and diarrhea.
Environment and Climate (SDGs 11 & 13): The environment determines the air we breathe and the water we drink. SDG 11 aims to improve urban living by addressing air quality in cities, directly tackling a major contributor to premature deaths (Target 3.9). Meanwhile, SDG 13 on Climate Action is critical, as climate-related hazards—from heatwaves to extreme weather—directly compromise public health infrastructure and human health.
Social Equity (SDGs 4 & 5): Education is a key predictor of health outcomes. SDG 4, by promoting quality education and health literacy, empowers individuals to make informed choices. SDG 5 on Gender Equality is essential for health, demanding the elimination of violence against women and girls and reinforcing sexual and reproductive health rights (a cross-cutting target with SDG 3.7).
The interdependence of the SDGs means that a failure to address an environmental or social problem outside the "health sector" is a failure for global health itself. The commitment to Good Health and Well-being is, therefore, a commitment to sustainable development in its entirety.