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Framework for Measurement of Service Coverage Dimension of Universal Health Coverage Ties Boerma, WHO Measuring and Monitoring Country Progress towards.

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Presentation on theme: "Framework for Measurement of Service Coverage Dimension of Universal Health Coverage Ties Boerma, WHO Measuring and Monitoring Country Progress towards."— Presentation transcript:

1 Framework for Measurement of Service Coverage Dimension of Universal Health Coverage Ties Boerma, WHO Measuring and Monitoring Country Progress towards UHC Concepts, Indicators, and Experiences Washington DC, 20 July 2012

2 Inputs & processes Health Financing Health workforce Infrastructure Information Governance Outputs Service access and readiness Service quality and safety Service Utilization Eligibility for a form of financial risk protection Outcomes Coverage of interventions Risk factors Impact Health status Financial risk protection Responsiveness Monitoring and evaluation results chain Level and distribution (equity)

3 Definitions 3 Access: whether the health services that people might need are available, of good quality, and close to them Coverage of interventions: whether the people who need an intervention actually receive it Effective coverage: whether the people who need health intervention obtain them in a timely manner and at a level of quality necessary to obtain the desired effect; health gain Obstacles to obtaining effective coverage: physical access, affordability, acceptability for reasons such as culture or religion, and poor service quality. Financial affordability is not only instrument but intrinsic goal Tanahashi T. Health service coverage and its evaluation. Bull WHO1978;56(2):295. Shengelia B, Murray CJL, Adams OB. Beyond Access and Utilization: Defining and Measuring Health System Coverage. Health Systems Performance Assessment: Debate, New Methods, and New Empiricism. Geneva: World Health Organization; 2003

4 4 |4 | Measuring progress towards the service coverage dimension of UHC – key issues to consider 4 Contents of the indicators/index Index or tracer indicators Equity dimension Output / proxy indicators Quality of services Measurement gaps Post 2015 development agenda Global and country perspectives

5 5 |5 | Contents of the indicators / index 5 Proven interventions with large health impact that can be measured MDG related interventions / communicable diseases: MNCH, HIV/TB/malaria Epidemiological transition - NCD and other interventions important : UNGA Political declaration 2011 monitoring plan; risk factors Injuries: emergency care, preventive measures Source: WHO. A comprehensive global monitoring framework including indicators and voluntary global targets for the prevention and control of NCD. Second discussion paper

6 Index or tracer indicators 6 Tracer indicators: selected interventions (no more than 5), target 100%, equity can be done well; disadvantage "gaming" Index based on intervention areas capturing the full range of services of UHC; intervention areas rather than indicators – Countdown MNCH coverage index Source: Boerma, J. T., J. Bryce, et al. (2008). "Mind the gap: equity and trends in coverage of maternal, newborn, and child health services in 54 Countdown countries." Lancet 371(9620): Coverage index gap: difference between poorest and wealthiest quintiles.

7 7 |7 | Equity dimension 7 Major weakness of the health MDGs UHC is about equity: should include levels and distribution according to key stratifiers. Intervention coverage among the poorest (or other disadvantaged population) could be a good tracer indicator of progress towards UHC. Excludes the use of statistical modeling to arrive at estimates Source: Country profile. Countdown 2015 for Maternal Newborn and Child Health

8 8 |8 | Input / Output proxy indicators 8 Inputs: money not suitable as proxy for access/coverage measure, but relevant Outputs: level and distribution of service outputs: index (SARA) –Service availability: density of infrastructure (facilities, beds) and specific services; proximity –Service readiness: a set of minimum conditions to provide services in terms of basic infrastructure, health workforce, diagnostics, treatment and universal precautions –Service utilization: OPD or admission rates Source: Data from NHSS China. Annual number of OPD visits per person, China OECD average (Range )

9 9 |9 | 9 Maternity beds density (per 1000 pregnant women) by district, Zambia Core health workers density (per population) by district, Zambia Example: service availability, 17 districts, SARA 2010, Zambia Source: Ministry of Health and WHO. Zambia service availability and readiness assessment Summary report. Geneva

10 Example: service readiness family planning, 8 districts, Zambia SARA 2008 and Source: Ministry of Health and WHO. Zambia service availability and readiness assessment Summary report. Geneva

11 Quality of care measurement 11 More complex, often many indicators (e.g. Agency for Healthcare Research and Quality (AHRQ) in USA over 200 indicators in use; OECD HCQI set of indicators linking quality of health services and health system performance Measurement more difficult; comparability an issue In low income setting service availability & readiness is a proxy for quality; SPA – exit interviews, observation; STI PI6 & PI7 experience Source: Data from NHSS China. Five-year cancer survival rates, OECD CervixBreast 30 day hospital mortality rates after AMI, OECD

12 12 | Measurement gaps & investments 12 Issues: (1) availability of good standard measurement method (2) data collection frequency (3) data quality Surveys: especially good on preventive intervention coverage measures; denominator (need) problems; 3-5 year intervals Facility data: quality data numerator, denominator projections; annual UHC monitoring will need investment in monitoring Surveys: NCD interventions especially need work Facility: improvement quality, transparency, innovation

13 13 | Post 2015 development agenda Possible linkages with UHC measurement 13 Development focus: –Inclusive economic development –Sustainable development –Human development: education, health, nutrition –Security All country focus instead of low income country focus Likely with only few health indicators at the top, covering all areas Health as an impact measure of development Health as contributor to development / beneficiary Health as human right Health status measure, e.g. (healthy) life expectancy, as summary measure (with equity) Universal health coverage good candidate

14 14 | Global and country perspectives 14 Global Few indicators, lessons learnt from the MDG monitoring Uniform targets Monitoring and reporting responsibilities clear Investment in measurement / monitoring Country Global framework and guidance Monitoring and reporting responsibilities clear Country specificity: different epidemiology, different priority interventions for UHC – flexible coverage index or different set of tracer indicators

15 Coverage index, based on intervention areas with tracer indicators within each areas

16 16 | Summary points 16 Service coverage as part of UHC can be measured and monitored but there will be measurement gaps especially for NCD (and curative care) Coverage index and set of tracer indicators with equity a key feature; focus on intervention "areas"; support with service output data Country-specificity including small "core" for global monitoring Combining coverage with financial protection into index would be ideal but challenging Only if the resulting measure is simple and appealing, UHC stands a chance of being included at a high level in the post 2015 development agenda monitoring

17 17 |

18 18 | Using Global Metrics to Measure Country Performance: Lessons Learned During the MDG Countdown Ties Boerma, WHO Measuring and Monitoring Country Progress towards UHC Concepts, Indicators, and Experiences Washington DC, 20 July 2012

19 Tracks country-level coverage for interventions proven to reduce maternal, newborn and child mortality and associated indicators for Policies and health system strength Financial flows Equity 75 countries with highest burden are the focus Collaboration of individuals, governments, organizations, partnerships Produces analytical reports, country profiles, global and regional events, Lancet series, link with parliamentarians, country Countdown

20 Coverage indicators Inclusion of coverage indicators driven by selection of proven interventions (continuum of care) Plus availability of reliable data to ascertain levels, trends, equity Use of household survey data (DHS, MICS) from 75 Countdown countries, from 1990; University of Pelotas data centre + analysis Upcoming PLoS Med series of papers to assess issues related to quality of coverage indicators Facility data are not used for coverage No use of model-based estimates for coverage

21 Coverage index: methods Aggregate index based on 4 intervention areas –family planning –maternal and newborn care –immunization –treatment of sick children Different system delivery strategies; captures overall strength of the delivery system (was original intention); can add intervention areas; equity The four intervention areas are given equal weight Strong association with health status measures Countdown 2008 Equity Analysis Group, Lancet 2008

22 Inputs & processes Health Financing Health workforce Infrastructure Information Governance Outputs Service access and readiness Service quality and safety Service Utilization Eligibility for a form of financial risk protection Outcomes Coverage Index Impact Health status Financial risk protection Responsiveness Monitoring and evaluation results chain Related to health system inputs/outputs and impact Level and distribution (equity)

23 Indicators in intervention areas TopicIndicators Family planningNeed for FP satisfied Maternal and newborn care Antenatal care (1+ visit) Skilled attendant at delivery ImmunizationBCG DPT3 Measles Treatment of sick children ORT Careseeking for pneumonia Countdown 2008 Equity Analysis Group, Lancet 2008

24 The overall mean = 57% –>80% in Turkmenistan and Peru –<30% in Ethiopia and Chad The coverage index improved by an average of 0.9 percentage point per year since the early 1990s –Based on 40 countries with more than one survey –Fastest improvements (>2 pp/year): Cambodia, Mozambique, and Nepal –Declining index: Chad, Kenya, Zambia, and Zimbabwe Countdown 2008 Equity Analysis Group, Lancet 2008 Empirical data: levels and trends

25 Monitoring equity in Countdown What types stratification? –Wealth quintiles –Maternal education –Urban/rural –Gender –Ethnic groups –Etc Photos: P Menzel

26 Countdown 2008 Equity Analysis Group, Lancet 2008 Coverage gaps by country

27 Coverage index changes over time: levels and inequity

28 Coverage index, based on intervention areas with tracer indicators within each areas

29 Summary points 29 Coverage index works well in Countdown to ascertain levels, trends and inequity; good way to summarize multiple interventions Mean coverage better understood by policy makers than coverage gap for CD – gap measure makes sense for UHC? Dependence on surveys a disadvantage; if facility based coverage estimates are good they should be used increasingly, at least for some indicators –Denominator problems: also with survey-based coverage rates UHC coverage index will need further methodological work, including the critical evidence based selection of core interventions Several aspects of the CountDown model deserve consideration for UHC monitoring, including country UHC monitoring, regular global analytical reports and country profiles

30 Acknowledgement 30 Countdown to 2015 colleagues, especially Jennifer Bryce and Cesar Victora


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