1. 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, 2004

2. 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

3. –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

4. 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

5. Structure of BMs B1-9 Main Goals –Criteria -- Key aspects Sub criteria-- main means or elements Evidence Base + Evaluation –Indicators –Scoring Rules

6. WHO Framework vs BM complementaryMove to reformsOverlap Subjectivity?Inform change?Problems Info, tr. peopleGood infoRequires VariousNational pol mkWho uses ScoresIndex, ranksProduct DeliberateMotivatePurpose Reform evalCurrent performObjective Nat, subnatCross nationalScope BMWHO

7. 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

8. 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

9. 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

10. 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

11. 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)

12. 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

13. 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

14. 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

15. Scoring Benchmarks Reform relative to status quo -50 +5 Or use qualitative symbols, --- or +++

16. 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

17. 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

18. 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

19. 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 IV: 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 allocation

20. 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.

21. Stage 3: Field testing Outputs: –Data collection tools for benchmarks I to V.

22. 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.

23. 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 population

24. 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

25. Indexes DISTRICTSIPSSIR SAN MIGUEL 0.510.29 CUBULCO 0.470.34 GRANADOS 0.380.81 SAN JERONIMO 0.360.38 PURULHA 0.330.59 EL CHOL 0.330.55 RABINAL 0.280.47 SALAMA 0.150.34

27. 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.

28. 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 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

29. CRITERIAINDICATORSRESULTS 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)

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

32. 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

33. 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)

34. 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.

35. 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)

36. 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

37. 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

38. 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.

39. 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

40. 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

41. 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