Technical Meeting for the Development of a Framework for Universal Access to Prevention, Care, Treatment and Support

in the Health Sector

WHO Executive Board RoomGeneva, 18-20 October 2005

CONCEPT OF UNIVERSAL ACCESS

Dr Michel Thieren (WHO/EIP/MHI)

Objectives of the session

• What are the lessons learnt from the conceptual debate and where does this debate currently stand?

• What does "universal" mean?• What does "access" mean?

• What determines and influences "universal access" and how to build a measurable framework upon them?

• What are the possible applications for universal access to HIV/AIDS prevention, treatment and care?

Objectives of the session

• What are the lessons learnt from the conceptual debate and where does this debate currently stand?

• What does "universal" mean?• What does "access" mean?

• What determines and influences "universal access" and how to build a measurable framework upon them?

• What are the possible applications for universal access to HIV/AIDS prevention, treatment and care?

1

Building up on the "coverage" debate

• Models or frameworks to explain / communicate but also to measure the concept of coverage– Piot - Fransen Model for STI– Tanahashi Model for Health Services– Phillips & Morisson Model of Access to Health Care

• Model or framework to track progress and measure achievement on coverage– Health System Effective coverage – Service Availability Mapping

Piot – Fransen Model for STI

Source: C.P. Hudson. Bulletin of the World Health Organization, 2001, 79 (1)

Tanahashi: Health Service Coverage Diagram

Source: Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2)

Availability Coverage

Contact Coverage

Acceptability Coverage

Accessibility (geo. & fin.) Coverage

Effectiveness Coverage

Target Population

Goal of service achievement

A Model of Access to Health Care

New definition of coverageNew definition of coverage

iij

iijij

j d

dCC

The probability of receiving a necessary health intervention conditional on the presence of a health care need

New definition of effective coverageNew definition of effective coverage

The magnitude of the realised health gain from the intervention relative to the potential health gain possible with the optimal performance of the providers for a given health system

n

iijijjkoptjkij

n

iijijij

j

dkYRPPHG

dCHGEC

1

1

...)1,1,1,(

Effective Coverage Model

7254

20

21

24

10

722

70

0%

100%

ART PMTCT Testing &counseling

Pe

rce

nt

of

dis

tric

ts

Two or more

One facility

No facility

Service Availability Mapping

Lessons learned

• Low level of agreement internationally• Some models are more complex than others• Some are more convincing to convey a comprehensive

message on access and coverage, others are more useful to monitor progresses on access and coverage

• The concepts are defined but there is broad space for flexibility

• It is not useful to push the conceptual debate further• It is more important to focus on how to take the various

concepts on board, agree on what they means for HIV/AIDS prevention, treatment and care and develop the framework accordingly

Objectives of the session

• What are the lessons learnt from the conceptual debate and where does this debate currently stand?

• What does "universal" mean?• What does "access" mean?

• What determines and influences "universal access" and how to build a measurable framework upon them?

• What are the possible applications for universal access to HIV/AIDS prevention, treatment and care?

2

The concepts (1)

• Health supply terms

– Availability– Affordability

• Health demand terms

– Utilisation– Acceptability

Access =

how much a population can reach health services

Coverage =

the share of a population eligible (beneficiaries) for a set of interventions

Concepts (2)

• Universal– Qualitatively, it gives a sense of equality, indivisibility– Quantitatively it can be "all" or "enough for everyone to get a

chance"

• Target– Can be an outcome, prevention, or treatment target– Scopes of target (global, country)– Targeted entity: % of population, population group, group at

risk, a group in need, districts, facilities … (measurability!!!!)

• Scaling-up– Expand geographically– diversify

• Intervention vs. services

Key points on the concepts (1):

• Use the term universal "access" instead or universal "coverage"

• • Avoid benchmarking "universal" in absolute terms

• Use of the term "coverage" associated with outcome (intervention) indicators

• The term "universal access" can be completed by its target expressed in "universal access at 80% of coverage" for a specific intervention

Key points on the concepts (2):

• Measuring "access" may actually measure just one or a few domains of access (like availability, affordability and/or acceptability), but rarely all of them

• Define country targets in national context instead of focusing on global targets

• Define target taking into account the measurability of the targeted entity (e.g. district or population)

• Overall, the concepts of access, coverage and associated terms are not standardized across programs, so there is room for flexibility.

Objectives of the session

• What are the lessons learnt from the conceptual debate and where does this debate currently stand?

• What does "universal" mean?• What does "access" mean?

• What determines and influences "universal access" and how to build a measurable framework upon them?

• What are the possible applications for universal access to HIV/AIDS prevention, treatment and care?

3

What determines effective coverage?What determines effective coverage?

• Price of intervention j offered by provider k – Bjk

• Disposable income of individual i - Ii

• Geographic location of a provider k offering intervention j in relation to individual i - Qijk

• Cultural and social acceptability of intervention j offered by provider k to individual i - Zjik

• Availability of necessary technology to provider k for delivering intervention j - Rjk

• Expected health gain from intervention - HGij

• Performance of provider k in relation to intervention j - Pjk

• Adherence of individual i to intervention j - Yij

ijjkijjjikijkijkijk YPHGRZQIBfEC ,,,,,,,

DATA COLLECTION & MEASUREMENT !!!

SAM administration processInterviewer : Respondent :

Date : District population :

The code numbers on this list are needed to f ill out the questionnaire.

New health facilities can be added at the end of the list

NAME CODE LAT LONG SUB-COUNTY COMMENT TYPE

Questionnaire programmed in

Palm Pilot

Enter data in PDA and upload

them in PC

Analysis of data and production of district mapping

Availability of in

terventions ii

at district (o

r facility

) levels?

96

83

7

7

0 20 40 60 80 100

Hemoglobin

Blood count

CD4+ cellcount

Liverfunctions

Building the framework

• Over-inclusive path

– WHO 2000-2003: the concept of effective coverage and its measurement problems

• Simplified path

– WHO 2005: the Service Availability Mapping Program focusing on availability only (is this enough?)

• Limit to what matters most

– Availability measured through SAM– Affordability equated to "free of charge" (SAM)– Acceptability population and/or facility based surveys

Key points: building a framework on Universal Access (1)

• Set the objective of the framework: – Communication: a comprehensive framework displaying all

the determinants of access and their inter-relationship is required.

– Monitoring and evaluation: the framework should be limited to measurable determinants.

• Consider a simplified (not simple!) approach to building a framework for universal access

• Focus on "availability" of core interventions in the area of prevention, treatment and care, at least at district level (SAM concept)

Key points: building a framework on Universal Access (2)

• Define the steps to be taken if additional factors are to be included: – "acceptability": could be measured for just a few

countries using population or facility based surveys; – "affordability" could be measured through household

surveys for a few countries or equated to the implementation of free services policies at districts level

• Promote academic debate and undertake research on how to extract measures from geographical information (i.e. computation of SAM generated availability data)

Objectives of the session

• What are the lessons learnt from the conceptual debate and where does this debate currently stand?

• What does "universal" mean?• What does "access" mean?

• What determines and influences "universal access" and how to build a measurable framework upon them?

• What are the possible applications for universal access to HIV/AIDS prevention, treatment and care?

4

Universal access in the context of HIV/AIDS treatment, prevention and care interventions

1. Universal access for treatment is treatment that is reachable, affordable and acceptable to all those in need

2. Universal access for prevention is along the same lines as for treatment: key prevention services should be reachable, affordable and acceptable to all those who need it: "all districts should have VCT, PMTCT, condoms, sex & AIDS education (general public, schools)", target population programs, which could be specified and could be measured

3. A core package of HIV/AIDS treatment, prevention and care interventions is defined, each one occurring in one of the four loci: hospital, health centre, community, home

4. The framework for universal access is target driven

Key points: building a universal access framework for HIV/AIDS (1)

• Build a framework for HIV/AIDS prevention, treatment and care using a core set of interventions covering the four primary loci of delivery: hospital, health centre, community, home

• Define country targets in terms of availability for these interventions at district level

• Borrow preventive targets from the MDG and UNGASS

Key points: building a universal access framework for HIV/AIDS (2)

• Propose "universal access at least 80% coverage" for a given intervention

• Or propose even further, "all districts should have at least 80% coverage, all sub (risk) populations at least 80% coverage"

• "Coverage" should be used primarily for "intervention" targeting; the number of targets should nonetheless be limited to avoid burdening measurement

WORKING GROUPS

1. WG1: Concepts and definitions

2. WG2: Determinants of universal access and their measurement issues

3. WG3: Country and global targets for universal access and their measurement issues

WG 1: Concepts and definitions

In reference to the background paper, the glossary of terms and the presentation on the concepts of universal access, coverage and other associated terms:

• Propose a set of terms that suits the context of universal access for HIV/AIDS treatment, prevention and care

• Propose definitions of these terms in the context of HIV/AIDS treatment, prevention and care

WG 2: Determinants of access

In reference to the background paper, the glossary of terms and the presentation on the concepts of universal access, coverage and their associated terms:

• Propose a set of determinants that suits the context of HIV/AIDS treatment, prevention and care

• List the measurement issues associated with these determinants

• Propose a measurement and data collection strategy for each of these determinants

WG 3: Principles for Setting Targets

In reference to the background paper, the glossary of terms and the presentation on the concepts of universal access, coverage and their associated terms:

• Propose a set of principles that should guide the selection of targets that suits the context of HIV/AIDS treatment, prevention and care

• Propose two global targets for treatment and prevention and examples for formulating them at country level

• List the measurement issues associated with these targets

• Propose a measurement and data collection strategy for each of these targets

WG 4: Principles for Prevention Targets

In reference to the background paper, the glossary of terms and the presentation on the concepts of universal access, coverage and their associated terms:

• Propose a set of principles that should guide the selection of targets that suits the context of HIV/AIDS treatment, prevention and care

• Propose two global targets for treatment and propose examples for formulating them at country level

• List the measurement issues associated with these targets

• Propose a measurement and data collection strategy for each of these targets