Benchmarks of fairness for public health: the experience in Guatemala Walter Flores and the Guatemalan team

Stage 1: Theoretical adaptation Conceptualizing public health The set of actions implemented through a health care system that includes personal, collective, environmental and health promotion interventions. The delivery of services can be done through public or private providers (with public funding) and its design and evaluation concerns to providers, financers (public and private) and regulators. Output: –Working document with specific version adapted to the context of Guatemala and Ecuador

Adapted benchmarks Defined by Daniels et al (2000) Benchmark I: Intersectorial Public Health Benchmark II: Financial barriers to equitable access Benchmark III: Nonfinancila barriers to access Benchmark IV: Comprehensiveness of benefits and tiering Benchmark V: Equitable financing Benchmark VI: Efficacy, efficiency and quality of care Benchmark VII: Administrative efficiency Benchmark VIII: Democtratic accountabily and empowerment Benchmark IX: Patient and provider autonomy Adaptation to Public Health Benchmark I: Intersectorial public health Benchmark II: Universal acces to public health interventions Preventive services, Curative services Social protection against catastrophic illness Reducción 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) Eficiency (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 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 (cuanti & cuali) 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 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 coeficient 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 population

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 percapita 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

Indexes DISTRICTSIPSSIR SAN MIGUEL CUBULCO GRANADOS SAN JERONIMO PURULHA EL CHOL RABINAL SALAMA

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.

CRITERIAINDICATORSRESULTS 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 to non-transmittable, chronic and degenerative diseases % health facilities at the district level offering services for the following problems: diabetes, hypertension, cardiovascular diseases, screening cervix 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

CRITERIAINDICATORSRESULTS Reduction of financial barriers% health facilities in a given districts 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 is 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 health facilities at the first level that experienced shortage of basic resources during last year -equipment -drugs -medical staff 30% (See table and graph for distribution) 59% (see table and graph for distribution) 25% (3 out of 12 facilities) (pending of tabulation)

Instrument #1b: Human Resources (feed analysis of non- financial barriers and inequities in the distribution of health personnel)

Lessons learned Benchmarks and its potential contribution for 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 collection 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.