benchmarks of fairness for health sector reform in developing countries: overview and latin american...
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Benchmarks of Fairness for Health Sector Reform in
Developing Countries: Overview and Latin American Applications
Norman Daniels
PIH, HSPH
Santiago, Chile, Jan 16, 2004
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, Zambia
–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 autonomy
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 efficiency
Structure of BMs
• B1-9 Main Goals– Criteria -- Key aspects
• Sub criteria-- main means or elements
• Evidence Base + Evaluation– Indicators– Scoring Rules
WHO Framework vs BM
complementaryMove to reformsOverlap
Subjectivity?Inform change?Problems
Info, tr. peopleGood infoRequires
VariousNational pol mkWho uses
Scores Index, ranksProduct
DeliberateMotivatePurpose
Reform evalCurrent performObjective
Nat, subnatCross nationalScope
BMWHO
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
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 benefits
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, disease
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, training
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)
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
evidence
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 advance
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 testing
Scoring Benchmarks
Reform relative to status quo
-5 0 +5
Or use qualitative symbols, --- or +++
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 problems
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 input
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
Adapted benchmarksDefined 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 IV: Comprehensiveness of benefits and tiering
Benchmark V: Equitable financingBenchmark VI: Efficacy, efficiency
and quality of careBenchmark VII: Administrative
efficiencyBenchmark VIII: Democratic
accountability and empowerment
Benchmark IX: Patient and provider autonomy
Adaptation to Public HealthBenchmark I: Intersectorial public
healthBenchmark II: Universal access to public
health interventionsPreventive services, Curative servicesSocial protection against catastrophic illnessReduction of financial barriersReduction non-financial barriers.Benchmark III: Equitable and sustainable
financingEquity in health financingSustainability in public financingBenchmark IV: Ensuring the delivery of
effective public health servicesTechnical quality (standard treatment
guidelines)Efficiency (relation between inputs and
outputs)User satisfactionBenchmark V: AccountabilitySocial participation, community involvement in the
evaluation and monitoring of inequities in health care delivery and resource allocation
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.
Stage 3: Field testing• Outputs:
– Data collection tools for benchmarks I to V.
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.
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 servicesCiin= Ideal coverage for immunization (100%)CDxin= Immunization coverage for district XCiap= Ideal coverage for antenatal care (100%)CDxap= Antenatal coverage for district XCipss=Ideal coverage for supervised deliveries (100%)CDxps=Coverage of supervised deliveries for district XVa= Sum of three values NOTES: The coefficient will go from 0.01 up to 0.99The higher the value, the higher the priority for the delivery of basic services to the population
INDEX OF RESOURCES
IR = (GPDx X 0.4 ) + (MDx X 0.3)+ (FDa X 0.3) GPDa MDa FDx
IR= Index of resourcesGPDx= per capita expenditure district xGPDa= District with the highest per capita expenditure MDx= Medical staff per population for district xMDa= District with the highest number of medical staff/popFDa= 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
IndexesDISTRICTS IPSS IRSAN MIGUEL 0.51 0.29CUBULCO 0.47 0.34GRANADOS 0.38 0.81SAN JERONIMO 0.36 0.38PURULHA 0.33 0.59EL CHOL 0.33 0.55RABINAL 0.28 0.47SALAMA 0.15 0.34
IPSS VERSUS IR
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
SAN MIGUELCHICAJ
CUBULCO GRANADOS SAN JERONIMO PURULHA EL CHOL RABINAL SALAMA
IPSS
IR
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.
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 area
CRITERIA INDICATORS RESULTSReduction 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 authorities100% (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)
Instrument #1b: Human Resources (feed analysis of non-financial barriers and inequities in the distribution of
health personnel)
PERSONNEL TOTAL WOMEN SPEAK LANGUAGEDoctors 12 2 0Nurses 16 16 2Auxiliary Nurses 17 17 2Rural health technicians 9 0 3Institutional facilitators 4 1 2Community facilitators 12 4 12
PERSONNEL
0 2 4 6 8 10 12 14 16 18
Doctors
Nurses
Auxiliary Nurses
Rural health technicians
Instiutional facilitators
Community facilitators
CA
TEG
OR
Y
NUMBER
SPEAK LANGUAGE
WOMEN
TOTAL
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 inequities
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)
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.
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)
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 indicators
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 law
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.
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 implementation
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),
Bangladesh
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