Benchmarks of Fairness for Health Sector Reform in Developi - PowerPoint Presentation

Slide1

Benchmarks of Fairness for Health Sector Reform in Developing Countries: Overview and Latin American Applications

Norman Daniels

PIH, HSPH

Ndaniels@hsph.harvard.edu

Santiago, Chile, Jan 16, 2004Slide2

Historical Development of the Benchmarks

1993 Clinton Task Force

1996 Benchmarks of Fairness for Health Care Reform – Oxford University Press.

Pilot work in Pakistan, 1997

1999-2000 Adaptation: Pakistan, Thailand, Colombia, Mexico:

Daniels, Bryant et al Bulletin of WHO, June 2000

2001-3 Demonstration Phase: Mexico, Portugal, Pakistan, Thailand; Vietnam Cameroon, Ecuador, Nicaragua, Guatemala, Chile, Yunnan (China), Sri Lanka, Bangladesh, ZambiaSlide3

The Adapted Benchmarks

1.

Intersectoral public health

2. Financial barriers to equitable access

3. Nonfinancial barriers to access

4. Comprehensiveness of benefits, tiering

5. Equitable financing

6.Efficacy,efficiency,quality of health care

7. Administrative efficiency

8. Democratic accountability, empowerment

9. Patient and provider autonomySlide4

Connections to social justice

Equity

B1Intersectoral public health, B2-3 Access, B4Tiering, B5 Financing

Democratic Accountability

B8, B9Choice

Efficiency

B6 Clinical Efficacy and quality

B7 Administrative efficiencySlide5

Structure of BMs

B1-9 Main Goals

Criteria -- Key aspects

Sub criteria-- main means or elements

Evidence Base + Evaluation

Indicators

Scoring RulesSlide6

WHO Framework vs BM

complementary

Move to reforms

Overlap

Subjectivity?

Inform change?

Problems

Info, tr. people

Good info

Requires

Various

National pol mk

Who uses

Scores

Index, ranks

Product

Deliberate

Motivate

Purpose

Reform eval

Current perform

Objective

Nat, subnat

Cross national

Scope

BM

WHO Slide7

B1: Intersectoral Public Health

Degree to which reform increases per cent of population (differentiated) with: basic nutrition, adequate housing, clean water, air, worplace protection, education and health education (various types), public safety and violence reduction

Info infrastructure for monitoring health status inequities

Degree reform engages in active intersectoral effort Slide8

B2: financial barriers to access

Nonformal sector

Universal access to appropriate basic package

Drugs

Medical transport

Formal Sector Social/Private Insurance

Encourages expansion of prepayment

Family coverage

Drug, med transport

Integrate various groups, uniform benefitsSlide9

B3: Nonfinancial barriers to access

Reduction of geographical maldistribution of facilities, services, personnel, other

Gender

Cultural -- language, attitude to disease, uninformed reliance on traditional practitioners

Discrimination -- race, religion, class, sexual orientation, diseaseSlide10

B6: Efficacy, efficiency and quality of health care

Primary health care focus

Population based, outreach, community participation, integration with system, incentives, appropriate resource allocation

Implementation of evidence based practice

Health policies, public health, therapeutic interventions

Measures to improve quality

Regular assessment, accreditation, trainingSlide11

B8: Democratic accountability and empowerment

Explicit public detailed procedures for evaluating services, full public reports

Explicit deliberative procedures for resource allocation (accountability for reasonableness)

Fair grievance procedures, legal, non-legal

Global budgeting

Privacy protection

Enforcement of compliance with rules, laws

Strengthening civil society (advocacy, debate)Slide12

Why is evidence base important?

Evidence base makes evaluation objective

Making evaluation objective means:

Explicit interpretation of criteria

Explicit rules for assessing whether criteria met and the degree to which alternatives meet them

Objectivity provides basis for policy deliberation

Gives points of disagreement a focus that requires reasons and evidenceSlide13

Evidence Base: Components

Adapted Criteria--convert generic benchmarks into country-specific tool

Reflect purpose of application

Reflect local conditions

Indicators

Outcomes

Process

revisability

Scoring rules

Connect indicators to scale of evaluation

Specify in advanceSlide14

Process of selecting indicators

Clarity about purpose

Type of criterion determines type of indicator

Outcomes vs process indicator appropriate

Standard vs invented for purpose

Requires clarity about mechanisms of reform

Availability of information

Consultation with experts

Final selection in light of tentative scoring rules

Further revision in light of field testingSlide15

Scoring Benchmarks

Reform relative to status quo

-5 0 +5

Or use qualitative symbols, --- or +++Slide16

Scoring Rules: General Points

Map indicator results onto

ordinal scale

of reform outcomes

Final selection of indicators should be done as scoring rules are developed, so refinements can be made

Scoring rules should be adopted prior to data collection to increase objectivity, but may have to be revised in light of problemsSlide17

Two approaches to evidence

Thailand: survey of various groups judging based on discussion of evidence

Strengths: range of views, involvement of larger groups

Weakness: vaguer basis for judgment?

Guatemala, Cameroon: team evaluation based on indicators, scoring rules

Strengths: clarity about evidence base for evaluation

Weakness: trained team, narrow inputSlide18

Guatemala, Ecuador:Stage 1: Theoretical adaptation

Conceptualizing public health

The set of actions implemented through a health care system which includes personal, collective, environmental and health promotion interventions. The delivery of services can be through public or private providers (with public funding) and its design and evaluation concerns providers, financers (public and private) and regulators.

Output:

Working document with specific version adapted to the context of Guatemala and Ecuador Slide19

Adapted benchmarks

Defined by Daniels et al (2000)

Benchmark I: Intersectorial Public Health

Benchmark II: Financial barriers to equitable access

Benchmark III: Non financial barriers to access

Benchmark I

V: Comprehensiveness of benefits and tiering

Benchmark V: Equitable financing

Benchmark VI: Efficacy, efficiency and quality of care

Benchmark VII: Administrative efficiency

Benchmark VIII: Democratic accountability and empowerment

Benchmark IX: Patient and provider autonomy

Adaptation to Public Health

Benchmark I: Intersectorial public health

Benchmark II: Universal access to public health interventions

Preventive services, Curative services

Social protection against catastrophic illness

Reduction of financial barriers

Reduction non-financial barriers.

Benchmark III: Equitable and sustainable financing

Equity in health financing

Sustainability in public financing

Benchmark IV: Ensuring the delivery of effective public health services

Technical quality (standard treatment guidelines)

Efficiency (relation between inputs and outputs)

User satisfaction

Benchmark V: Accountability

Social participation, community involvement in the evaluation and monitoring of inequities in health care delivery and resource allocationSlide20

Stage 2: Data collection and data analysis tools

Intervention level: Province/Department

Decentralization transferred policy-implementing responsibilities and resources to the sub-national level. Development of tools and field testing follows from the provincial to the municipal level.

Outputs:

Data collection: questionnaires (quantitative & qualitative) to assess criteria and indicators for each benchmark

Data analysis: index to assess inequities, health expenditures analysis through proxies (drug consumption), excel database. Slide21

Stage 3: Field testing

Outputs:

Data collection tools for benchmarks I to V.Slide22

Examples of application

Starting with an analysis of inequities in the delivery of basic health care services and inequities in the distribution of basic resources. Slide23

INDEX OF PRIORITY FOR HEALTH SERVICE (IPSS)

IPSS= (

Ciin-CDxin ) +

(

Ciap-CDxap )+

(

Cips-CDxps ) Va

Ciin Ciap Cips 3

IPSS= Index of priority for health services

Ciin= Ideal coverage for immunization (100%)

CDxin= Immunization coverage for district X

Ciap= Ideal coverage for antenatal care (100%)

CDxap= Antenatal coverage for district X

Cipss=Ideal coverage for supervised deliveries (100%)

CDxps=Coverage of supervised deliveries for district X

Va= Sum of three values

NOTES: The coefficient will go from 0.01 up to 0.99

The higher the value, the higher the priority for the delivery of basic services to the populationSlide24

INDEX OF RESOURCES

IR = (

GPDx

X 0.4 ) + (

MDx

X 0.3)+ (

FDa

X 0.3)

GPDa MDa FDx

IR= Index of resources

GPDx= per capita expenditure district x

GPDa= District with the highest per capita expenditure

MDx= Medical staff per population for district x

MDa= District with the highest number of medical staff/pop

FDa= District with the highest number of health facilities per population (district with the lowest number of inhabitants per health facility)

FDx= health facility per population in district x

Slide25

Indexes

DISTRICTS

IPSS

IR

SAN MIGUEL

0.51

0.29

CUBULCO

0.47

0.34

GRANADOS

0.38

0.81

SAN JERONIMO

0.36

0.38

PURULHA

0.33

0.59

EL CHOL

0.33

0.55

RABINAL

0.28

0.47

SALAMA

0.15

0.34Slide26
Slide27

Examples of application

Benchmark II: Universal access to integrated public health services

Definition of integrated public health: the delivery of services related to curative, preventive and health promotion, as well as services for both, transmittable and non-transmittable diseases and chronic diseases. An integrated effort should include some forms of protection against catastrophic diseases

.Slide28

CRITERIA

INDICATORS

RESULTS

Access to the curative services included in the basic package of services

% of population receiving the services at any of the three subsystems (public, social security and private) with public funding

N/A

Access to preventive services included in the basic package of services

% of population receiving the services at any of the three subsystems (public, social security and private) with public funding

N/A

The provision of services aimed at non-transmittable, chronic and degenerative diseases

% health facilities at the district level offering services for the following problems: diabetes, hypertension, cardiovascular diseases, screening cervical cancer

42%

(5 facilities from a total of 12)

Actions implemented aimed to protect the individuals against the socio-economic consequences of catastrophic illnesses

% of health districts or municipalities that have a catastrophic disease fund for their population

0%. This type of benefit does not exist in the areaSlide29

CRITERIA

INDICATORS

RESULTS

Reduction of financial barriers

%

health facilities in a given district in which the population contributes with cash or in kind resources to the delivery of basic health care services (both curative and preventive)

0% (interviews to health authorities

100% (focus groups with community members)

Reduction of non- financial barriers

% of health personnel (by category) that speak the local indigenous language

 % of health staff (by category) who are women

 % of health facilities offering services in a schedule that is appropriate to the occupation and schedules of the local population (24 hours emergency; OPD services offered until late evening)

 % of first level health facilities that experienced shortage of basic resources during last year (equipment, drugs, medical staff)

30%

(see table & graph for distribution)

59%

(see table &graph for distribution)

25% (3 out of 12 facilities)

(pending tabulation)Slide30

Instrument #1b:

Human Resources (feed analysis of non-financial barriers and inequities in the distribution of health personnel)Slide31
Slide32

Lessons learned

Benchmarks and their potential contribution to the analysis of inequities

Start by analyzing inequities in the delivery of basic health services and inequities in the distribution of basic resources

From here the benchmarks can help to explain the factors that may be related to the observed inequitiesSlide33

Lessons learned

Difficulties of transferring concepts into practice

Identifying and assessing indicators for accountability, social participation, intersectorial work, etc.

Limitations related to health information systems

Existing system collects mainly traditional information (health service production) and has little flexibility to introduce new indicators (intersectorial work and others)Slide34

Lessons learned

Skills in research team

Actors at sub-national levels require skills development

Qualitative research

Potential users and data collectors have little experience & skills for qualitative research

Planning cycle

The benchmarks approach seems more useful as an approach that helps the planning cycle: evaluate existing situation-design interventions-implement-evaluate. Issues related to equity and social justice within the health system can be addressed in each of the stages of the planning cycle. Slide35

Ecuador

Team members:

12 people representing the following institutions:

Universidad Nacional de Loja, PAHO-Ecuador, ALDES, Universidad de Cuenca, Fundación Eugenio Espejo, Harvard School of Public Health (USA) Liverpool School of Tropical Medicine (UK)

Slide36

Work carried out during the year 2003

5 workshops (two days per workshop)

9 work-meetings (one day or less)

Outputs:

Adapted version to Ecuador of the generic matrix (Daniels et al 2000) with specific indicators for each benchmarks’ criteria

Development of data collection instruments to assess indicatorsSlide37

Adaptation of generic matrix

Followed simmilar process to Guatemala

Exchange of ideas and indicators between the Guatemalan team and the Ecuadorian team.

Adaptation in Ecuador emphasize the assessment of recent health policies: national health system law, free MCH services lawSlide38

Field application (Jan-April 2004)

Two provinces: Azuay y Canar

25 health facilities (11 MoH 7 social security; 7 NGO’s; 1 local government.

In addition, a household survey that will allow to investigate socio-economic inequalities and its relation with access to reproductive health and MCH services.Slide39

Expected use of findings (field application)

Inform local government health plans

Inform advocacy groups in Azuay and Canar

Field testing of the benchmarks approach as a tool that can aid the monitoring and evaluation of health policy implementationSlide40

APHA Later

Thailand

Guatemala

Cameroon

Zambia--HIV/AIDS

Yunnan, China-rural reform

Ecuador, public health, comprehensive

Vietnam-comprehensive reform

Pakistan- community use

Chile, Nicaragua, Sri Lanka, Nigeria (ACOSHED), BangladeshSlide41

Plans for Benchmarks

Research Network for all sites, other efforts at monitoring reform

Funding for country level projects using adapted benchmarks

Coordination with WHO, regional organizations of WHO, World Bank, USAID