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Benchmarks of Fairness for Health Sector Reform in Developing Countries: Overview and Latin American Applications


Guatemala, Cameroon: team evaluation based on indicators, scoring rules ... Cameroon. Zambia--HIV/AIDS. Yunnan, China-rural reform. Ecuador, public health, ... – PowerPoint PPT presentation

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Title: Benchmarks of Fairness for Health Sector Reform in Developing Countries: Overview and Latin American Applications

Benchmarks of Fairness for Health Sector Reform
in Developing Countries Overview and Latin
American Applications
  • Norman Daniels
  • Santiago, Chile, Jan 16, 2004

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

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

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

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

WHO Framework vs BM
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
  • Degree reform engages in active intersectoral

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

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

B6 Efficacy, efficiency and quality of health
  • 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
  • Measures to improve quality
  • Regular assessment, accreditation, training

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)

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
  • Gives points of disagreement a focus that
    requires reasons and evidence

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

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
  • Further revision in light of field testing

Scoring Benchmarks
Reform relative to status quo -5 0
5 Or use qualitative symbols, --- or
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

Two approaches to evidence
  • Thailand survey of various groups judging based
    on discussion of evidence
  • Strengths range of views, involvement of larger
  • Weakness vaguer basis for judgment?
  • Guatemala, Cameroon team evaluation based on
    indicators, scoring rules
  • Strengths clarity about evidence base for
  • Weakness trained team, narrow input

Guatemala, Ecuador Stage 1 Theoretical
  • 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

Adapted benchmarks
  • Adaptation to Public Health
  • Benchmark I Intersectorial public health
  • Benchmark II Universal access to public health
  • Preventive services, Curative services
  • Social protection against catastrophic illness
  • Reduction of financial barriers
  • Reduction non-financial barriers.
  • Benchmark III Equitable and sustainable
  • 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
  • Defined by Daniels et al (2000)
  • Benchmark I Intersectorial Public Health
  • Benchmark II Financial barriers to equitable
  • Benchmark III Non financial barriers to access
  • Benchmark IV Comprehensiveness of benefits and
  • Benchmark V Equitable financing
  • Benchmark VI Efficacy, efficiency and quality of
  • Benchmark VII Administrative efficiency
  • Benchmark VIII Democratic accountability and
  •  Benchmark IX Patient and provider autonomy

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.

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

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 CipssIdeal coverage for
supervised deliveries (100) CDxpsCoverage 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
IR (GPDx X 0.4 ) (MDx X 0.3) (FDa X 0.3)
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

SAN MIGUEL 0.51 0.29
CUBULCO 0.47 0.34
GRANADOS 0.38 0.81
SAN JERONIMO 0.36 0.38
PURULHA 0.33 0.59
EL CHOL 0.33 0.55
RABINAL 0.28 0.47
SALAMA 0.15 0.34
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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.

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

Lessons learned
  • Difficulties of transferring concepts into
  • 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
  • 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.

  • 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)

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

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

Field application (Jan-April 2004)
  • Two provinces Azuay y Canar
  • 25 health facilities (11 MoH 7 social security
    7 NGOs 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.

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

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),

Plans for Benchmarks
  • Research Network for all sites, other efforts at
    monitoring reform
  • Funding for country level projects using adapted
  • Coordination with WHO, regional organizations of
    WHO, World Bank, USAID