Measuring Health Systems Performance and NHA: Agenda for Health Services Research and Evaluation

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Measuring Health Systems Performance and NHA
Agenda for Health Services Research and
Evaluation

• Akiko Maeda, Ph.D.
• Lead Health Specialist
• Europe and Central Asia Region
• The World Bank

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Introduction

• NHA role in measuring health system performance
• Challenges in measuring efficiency and quality of
  health care
• Need for improved data collection and evaluation
  tools
• Agenda for health services research evaluation
  NHA in developing countries

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Health Sector Resource Allocation Utilization
Questions

• How large is the sector?
• What are its constituent parts?
• What items currently dominates in resource
  allocation?
• Who pays for what, and what services do they get
  for their payment?

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Measuring Health Systems Performance

• Revenues /Inputs
• Redistribution (progressive?)
• Administrative Efficiency
• Risk-pooling/ Insurance

• Health Services Throughputs
• Allocative Efficiency
• Microecon. efficiency
• Efficacy/ Effectiveness

• Health Outcomes
• Aggregate
• Disease specific
• Socio-economic factors

NHA defines financial flows from sources to
service outputs
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NHA Flow of Funds Analysis
SHA Coding
Sources of Funds
ICHA-HF
Financial Intermediaries
Uses of Funds - By Institutions - By Functions
ICHA-HP
ICHA-HC
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Why Health Accounts?

• Health accounts offer
• Consistent and comprehensive definition of
  health system taxonomy and boundaries, for
  comparability
• Classification of resource inputs and
  throughputs , by functional and organizational
  categories
• A method for costing (valuation of) health
  transactions for comparability, normative
  evaluation

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Measuring Health System Performance

• Outcome/Inputs Cost-benefit, cost effectiveness
  analysis, e.g., reduction in disease incidence
  rate per
• Outputs/Inputs Efficiency measure based on
  intermediate process indicators, e.g., cost per
  hospitalization case
• Outcome/Outputs Effectiveness/ efficacy of
  intervention, e.g., immunization rate and
  reduction in disease incidence.

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Challenges for improving the relevance of NHA

• NHA offers a consistent framework for
  measurement, but does not offer normative
  measures
• Difficult to evaluate performance based only on
  aggregate expenditure data
• Need complementary indicators of efficiency and
  quality appropriateness of care, productivity
  measures, and other benchmarks
• Poor quality and incomplete data at micro-level
  (provider) limits usefulness of aggregate data

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Measuring Efficiency of Health System
Challenges

• Major gap between aggregate macro-level data
• ....And microeconomic performance data
• at provider and population level

GAP
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Challenges in Comparing Health System Performance

• Variability in the organization of health care
  delivery system
• Dynamically evolving technology e.g., increasing
  use of day surgeries, decreasing acute care
  hospitalization days
• Internal variability in performance among
  providers and outcome among population groups
• Confounding factors complex interactions between
  socio-economic factors and health outcomes

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Example Using NHA to evaluate Estimating
Allocative Efficiency

• NHA functional categories e.g., public health
  programs, acute vs. chronic inpatient care
  provides common framework for defining products,
  but needs to be adjusted for
• Intensity, quality of care
• Population demographic profile
• Evidence of clinical efficacy, cost-effectiveness

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What can we tell from these aggregate expenditure
data...?
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Agenda for Research

• Developing data collection and research capacity
  in the following areas
• Household consumption and expenditure surveys,
  with improved designs on medical services
  purchased directly or through insurance
• Health care provider utilization surveys
• Improved quality of expenditure data at provider
  level (case-mix, medical procedures)

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Agenda for NHA in Developing Countries

• Review of classification of services
• Need to review, adapt OECD SHA functional and
  provider classifications to suit developing
  country health systems
• Health services research agenda
• Developing affordable instruments for collecting
  data at provider (private public) and
  population groups

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Examples of Priority Topics for Health System
Research

• Rational Use of Drugs
• Hospitalization tracking changes in acute and
  chronic care admission rates, length of stay
• Administrative efficiency
• Public health programs allocation on prevention
  and population-based programs versus personal/
  clinical interventions

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Agenda for Health System Research

• Recommendations
• Focus greater attention on capacity building on
  health services research and evaluation
• Introduce National Health Accounts within the
  context of health services evaluation, not as a
  stand-alone instrument
• With improved quality of data, it should become
  more feasible to undertake meaningful national
  and international comparisons

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Agenda for Health System Research

• World Banks standard economic and sector work
  focuses on Public Expenditure Reviews (PER) and
  Household Surveys (e.g., Living Standards
  Measurement Surveys)
• Complementary capacity building should focus on
  supporting provider surveys, operational
  research on services

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Measuring Health System Performance Instruments
Provider Surveys
Public Expenditure Reviews
Household Surveys
Health Systems Performance Evaluation
Administrative Data
Quality utilization reviews, technology
assessment, demo. epid. analyses
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Health System Performance Evaluation -

• Low-income countries
• Administrative data may be of limited value
• Limited data on private sector activities
• May need additional surveys to evaluate
  performance
• Middle Income Countries
• Improved capacity to collect performance-based
  data through regular operational and regulatory
  systems

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Health System Evaluation Process
NHA framework on resource flows
Analysis of Outputs, outcomes and Expenditures
Utilization and Quality Reviews
Clinical and epidemiological outcomes
Evidence-Based Medicine
Service benchmarks
Cost-effectiveness Analysis
Provider level
Population groups
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• Contact Akiko Maeda
• Address The World Bank H7-700
• 1818 H. St. N.W., Washington, D.C. 20433
• USA
• Telephone [phone]
• Email amaeda_at_worldbank.org