1. Monitoring Provision and Quality of Services Bakhuti Shengelia Regional Adviser for Health Policy and Equity Division of Country Health Systems WHO-EURO Health System Metrics Meeting Glion, September 28-29, 2006

2. The Goals and Functions of Health Systems Health Financing (collecting, pooling and purchasing Creating resources (investment and training ) Stewardship (oversight) Fair financial contribution Responsiveness (to peoples non-medical expectations) Delivering services (provision) OUTCOMES INPUTS

3. The US Health System Performance Scorecard Framework Long, healthy & productive lives QualityAccessEfficiencyEquity Mortality amenable to health care The right careUniversal participation Potential overuse Long healthy and productive lives Efficiency in access Infant mortalityCoordinated care Variation in quality and costs Quality HALE at age 60 Safe care Patient-centred, Affordability Universal participation and affordability Insurance admin. Costs Activity limitation under age 65 Coordinated and efficient care Info systems to support efficiency Children school absenteeism timely care

4. How Does the US Perform?

5. EURO Health Consumer Index DomainsIndicatorsRelative weight Patient rights and information101.5 Waiting time for treatment52.0 Outcomes62.0 Provision levels (Generosity of the public health care system) 31.0 Pharmaceuticals (Access to new drugs, speed of development of novel cancer drugs, etc.) 41.0

7. Health System Performance Dimensions QUALITY AccessCost/ Expenditure Health care needs EffectivenessSafetyResponsiveness / Patient centeredness Staying healthy Getting better Living with illness or disability Coping with end of life Outcomes Process Structure OECD FRAMEWORK

8. Challenges for the Framework Capturing the parameters strictly specific to health service delivery function Universality Accommodating differences in the level of health system development and the resources Keeping pace with development of knowledge and technology Adapting to the changing health care needs

9. Multi Tier Framework for Service Delivery Physical access Waiting time Amenities Affordability Efficiency of infrastructure Productivity of human resources Use of pharmaceuticals Efficiency of operations Accessibility Quality Technical efficiency Efficiency Effective coverage Equity Safety Appropriateness Adequate supplies and technology Effectiveness

10. Definition of Effective Coverage Probability for an individual of receiving potential health gain if needed Quality Utilization Intervention Need

11. Accessibility Physical proximity to the provider –Average travel time to the nearest emergency care department, general practitioner, specialist, hospital, maternity, pharmacy, etc. (or % of the population whose physical access is below a special benchmark value) –Average elapse time between the placement of a call and the arrival of ambulance. Waiting time –Family doctor same day service –Elective surgery waiting time (hernia, hip replacement, etc.) –Cancer surgery waiting time

12. Quality Availability of adequate technologies and supplies (in hospitals, outpatient clinics, pharmacies) –Essential drugs, diagnostic and laboratory equipment, other supplies. Appropriateness – the right care –The choice of an intervention, treatment protocols, diagnostic method (e.g. all recommended doses of a vaccine; antiplatelate, beta-blocker and statin use for the treatment of IHD; periodic retinal examination of diabetic patients, mammography, etc.)

13. Patient safety –Rate of medical errors –Rate of unsafe medical practices –Blood safety –Hospital infection rates Effectiveness –>5 year cancer survival rates –In hospital mortality rates (Acute Myocardial Infarction 30-day case- fatality rate, major amputations in diabetic patients, in-partum mortality rates, etc.) Coordinated care (particularly relevant for chronic conditions) –Follow up of newborns health after the mothers discharge from the hospital –Follow up after hospital discharge –Coordination/integration of STI and family planning services

14. Efficiency Efficiency of infrastructure –Number of acute hospital beds per population –Number of hospitals per population –Number of major medical equipment (CT scanners, MRI, etc.) per population Productivity of human resources –Average number of annual patient consultations in outpatient clinic per doctor Use of pharmaceuticals –Share of generic prescriptions Efficiency of operations –Average length of stay –Bed occupancy rate –% of the hospital budgets spent on medical services

15. Dashboard Indicators Effective coverage for 10-20 critical interventions Coverage Proportion of the population who can reach (a) the emergency care within 30 minutes, (b) outpatient health care provider within 1 hour, and (c) hospital within 2 hours. Access Elective surgery waiting time (hernia, cancer) Waiting time for a consultation with a specialist

16. Availability of 30 most essential medicines at secondary-level hospitals Quality Availability of 10 most essential laboratory tests at secondary- level hospitals Availability of calibrated sphygmomanometer at the GP clinics Safety of blood products Vaccination with all recommended doses of standard vaccines Periodic check-ups for the signs of eclampsia and anaemia during antenatal care. Regular retinal examination among the diabetic patients Hospital infection rates In-partum mortality rates Case-mix adjusted hospital mortality 5 year cancer survival rate

17. Bed occupancy rate Efficiency CT scanners per population Proportion of hospitals with less than 100 beds Rate of generic prescriptions Expenditure on direct patient care as % of total recurrent expenditure Average number of patient consultations per physician

18. Domains YearValueScoreTrend in the last 5 years Effective coverage200360%85 Access Physical access2003 50 Waiting time200370 Quality Safety200380 Effectiveness200370 Appropriateness200365 Adequate supplies & technology200360

19. Implications For Measurement Building effective coverage measures into population surveys Improving the quality measures at outpatient level Greater investment in facility surveys