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Framework for Measurement of Service Coverage Dimension of
Universal Health Coverage
Ties Boerma, WHO
Measuring and Monitoring Country Progress towards UHC Concepts, Indicators, and Experiences
Washington DC, 20 July 2012
Inputs & processes
Health Financing
Health workforce
Infrastructure
Information
Governance
Outputs
Service accessand readiness
Service qualityand safety
ServiceUtilization
Eligibility for a form of
financial risk protection
Outcomes
Coverage ofinterventions
Risk factors
Impact
Health status
Financial risk protection
Responsiveness
Monitoring and evaluation results chain
Level and distribution (equity)
Definitions
3
• Access: whether the health services that people might need are available, of good quality, and close to them
• Coverage of interventions: whether the people who need an intervention actually receive it
• Effective coverage: whether the people who need health intervention obtain them in a timely manner and at a level of quality necessary to obtain the desired effect; health gain
• Obstacles to obtaining effective coverage: physical access, affordability, acceptability for reasons such as culture or religion, and poor service quality.
• Financial affordability is not only instrument but intrinsic goal
Tanahashi T. Health service coverage and its evaluation. Bull WHO1978;56(2):295. Shengelia B, Murray CJL, Adams OB. Beyond Access and Utilization: Defining and Measuring Health System Coverage. Health Systems Performance Assessment: Debate, New Methods, and New Empiricism. Geneva: World Health Organization; 2003
4 |
Measuring progress towards the service coverage dimension of UHC – key issues to consider
4
● Contents of the indicators/index
● Index or tracer indicators
● Equity dimension
● Output / proxy indicators
● Quality of services
● Measurement gaps
● Post 2015 development agenda
● Global and country perspectives
5 |
Contents of the indicators / index
5
● Proven interventions with large health impact that can be measured
● MDG related interventions / communicable diseases: MNCH, HIV/TB/malaria
● Epidemiological transition - NCD and other interventions important : UNGA Political declaration 2011 monitoring plan; risk factors
● Injuries: emergency care, preventive measures
Indicators and targets for 2025for the global monitoring framework for NCDs
Mortality between ages 30 and 70 due to CVD, cancer, diabetes, and chronic respiratory disease
25% reduction
Hypertension25% reduction
Tobacco30% reduction
Salt30% reduction
Physical inactivity
10% reduction
Indicatorswith targets
Other country-specific indicators of NCD and related issues including social determinants of health
OtherWHO core indicators
* All indicators should be disaggregated by gender, age, socioeconomic position, and other relevant stratifiers
Policies to virtually eliminate trans fats and to reduce marketing of unhealthy foods to children
Overweight/obesity (adult, child, adolescent)
Raised blood glucose/diabetes
Raised total cholesterol
Access to basic technologies and medicines
Cervical cancer screening
Cancer incidence, by type Multidrug therapy for CVD risk reduction
Access to palliative care
Vaccination: HPV, Hepatitis BAdult per capita consumption of alcohol and heavy episodic drinking
Low fruit and vegetable intake
Source: WHO. A comprehensive global monitoring framework including indicators and voluntary global targets for the prevention and control of NCD. Second discussion paper. 2012.
Index or tracer indicators
6
• Tracer indicators: selected interventions (no more than 5), target 100%, equity can be done well; disadvantage "gaming"
• Index based on intervention areas capturing the full range of services of UHC; intervention areas rather than indicators – Countdown MNCH coverage index
Source: Boerma, J. T., J. Bryce, et al. (2008). "Mind the gap: equity and trends in coverage of maternal, newborn, and child health services in 54 Countdown countries." Lancet 371(9620): 1259‐1267.
Coverage index gap: difference between poorest and wealthiest quintiles.
7 |
Equity dimension
7
● Major weakness of the health MDGs
● UHC is about equity: should include levels and distribution according to key stratifiers.
● Intervention coverage among the poorest (or other disadvantaged population) could be a good tracer indicator of progress towards UHC.
● Excludes the use of statistical modeling to arrive at estimates
Source: Country profile. Countdown 2015 for Maternal Newborn and Child Health. 2012.
8 |
Input / Output proxy indicators
8
● Inputs: money not suitable as proxy for access/coverage measure, but relevant
● Outputs: level and distribution of service outputs: index (SARA)– Service availability: density of
infrastructure (facilities, beds) and specific services; proximity
– Service readiness: a set of minimum conditions to provide services in terms of basic infrastructure, health workforce, diagnostics, treatment and universal precautions
– Service utilization: OPD or admission rates
Source: Data from NHSS China.
0
2
4
6
8
1993 1998 2003 2008
Annual number of OPD visits per person, China 1993-2008
OECD average)Range 2.5-13 (
9 |9
Maternity beds density (per 1000 pregnant women) by district, Zambia 2010.
Core health workers density (per 10 000 population) by district, Zambia 2010.
Example: service availability, 17 districts, SARA 2010, Zambia
Source: Ministry of Health and WHO. Zambia service availability and readiness assessment 2010. Summary report. Geneva. 2012.
Example: service readiness family planning, 8 districts, Zambia SARA 2008 and 2010
10
Source: Ministry of Health and WHO. Zambia service availability and readiness assessment 2010. Summary report. Geneva. 2012.
Quality of care measurement
11
• More complex, often many indicators (e.g. Agency for Healthcare Research and Quality (AHRQ) in USA over 200 indicators in use; OECD HCQI set of indicators linking quality of health services and health system performance
• Measurement more difficult; comparability an issue
• In low income setting service availability & readiness is a proxy for quality; SPA – exit interviews, observation; STI PI6 & PI7 experience
Source: Data from NHSS China.
Five-year cancer survival rates, OECDCervix Breast
30 day hospital mortality rates after AMI, OECD
12 |
Measurement gaps & investments
12
● Issues: (1) availability of good standard measurement method (2) data collection frequency (3) data quality
● Surveys: especially good on preventive intervention coverage measures; denominator (need) problems; 3-5 year intervals
● Facility data: quality data numerator, denominator projections; annual
● UHC monitoring will need investment in monitoring
● Surveys: NCD interventions especially need work
● Facility: improvement quality, transparency, innovation
13 |
Post 2015 development agendaPossible linkages with UHC measurement
13
● Development focus:– Inclusive economic development– Sustainable development– Human development: education,
health, nutrition– Security
● All country focus instead of low income country focus
● Likely with only few health indicators at the top, covering all areas
● Health as an impact measure of development
● Health as contributor to development / beneficiary
● Health as human right
● Health status measure, e.g. (healthy) life expectancy, as summary measure (with equity)
● Universal health coverage good candidate
14 |
Global and country perspectives
14
Global
●Few indicators, lessons learnt from the MDG monitoring
●Uniform targets
●Monitoring and reporting responsibilities clear
●Investment in measurement / monitoring
Country
●Global framework and guidance
●Monitoring and reporting responsibilities clear
●Country specificity: different epidemiology, different priority interventions for UHC – flexible coverage index or different set of tracer indicators
Table 1: Intervention areas, tracer indicators and additional indicators for coverage index.
Intervention area Tracer indicators Additional indicators Child vaccination DPT3/penta, measles BCG, polio, hepB
Maternity care ANC 4 or more visits, skilled birth attendance
ANC 1+ visit, institutional delivery, postnatal care
Family planning Unmet need for FP Contraceptive use
Treatment of sick children
Suspected pneumonia taken to health facil ity, diarrhoea with ORT
Suspected pneumonia treated with antibiotics, diarrhoea treated with ORS
Malaria Children sleeping under ITN; IPT during pregnancy
Fever treated with antimalarials/ACT; households with IRS
TB TB treatment success rate; TB case detection rate
HIV prevention Condom use at higher risk sex; PMTCT among HIV positive women; ART
Male circumcision rate
Cancer HPV vaccination; tobacco use*; cervical cancer screening
5 year survival rate (specific cancer); mammography
Cardiovascular diseases
Hypertension prevalence* Salt intake*; hypertension control follow-up visit; AMI survival; physical activity*
Mental health Injuries
Other NCD Asthma (re)admission rate; cataract surgery
* risk factors
Coverage index, based on intervention areas with tracer indicators within each areas
16 |
Summary pointsSummary points
16
Service coverage as part of UHC can be measured and monitored but there will be measurement gaps especially for NCD (and curative care)
Coverage index and set of tracer indicators with equity a key feature; focus on intervention "areas"; support with service output data
Country-specificity including small "core" for global monitoring
Combining coverage with financial protection into index would be ideal but challenging
Only if the resulting measure is simple and appealing, UHC stands a chance of being included at a high level in the post 2015 development agenda monitoring
17 |
18 |
Using Global Metrics to Measure Country Performance: Lessons Learned
During the MDG Countdown
Using Global Metrics to Measure Country Performance: Lessons Learned
During the MDG Countdown
Ties Boerma, WHO
Measuring and Monitoring Country Progress towards UHC Concepts, Indicators, and Experiences
Washington DC, 20 July 2012
Tracks country-level coverage for interventions proven to reduce maternal, newborn and child mortality and associated indicators for Policies and health system strength Financial flows Equity
75 countries with highest burden are the focus
Collaboration of individuals, governments, organizations, partnerships
Produces analytical reports, country profiles, global and regional events, Lancet series, link with parliamentarians, country Countdown
Coverage indicators
Inclusion of coverage indicators driven by selection of proven interventions (continuum of care)
Plus availability of reliable data to ascertain levels, trends, equity
Use of household survey data (DHS, MICS) from 75 Countdown countries, from 1990; University of Pelotas data centre + analysis Upcoming PLoS Med series of papers to assess issues related to quality of
coverage indicators
Facility data are not used for coverage No use of model-based estimates for coverage
Coverage index: methods
• Aggregate index based on 4 intervention areas – family planning– maternal and newborn care– immunization– treatment of sick children
• Different system delivery strategies; captures overall strength of the delivery system (was original intention); can add intervention areas; equity
• The four intervention areas are given equal weight • Strong association with health status measures
Countdown 2008 Equity Analysis Group, Lancet 2008
Inputs & processes
Health Financing
Health workforce
Infrastructure
Information
Governance
Outputs
Service accessand readiness
Service qualityand safety
ServiceUtilization
Eligibility for a form of
financial risk protection
Outcomes
CoverageIndex
Impact
Health status
Financial risk protection
Responsiveness
Monitoring and evaluation results chainRelated to health system inputs/outputs and impact
Level and distribution (equity)
Indicators in intervention areas
Topic IndicatorsFamily planning Need for FP satisfied
Maternal and newborn care
Antenatal care (1+ visit)Skilled attendant at delivery
Immunization BCGDPT3Measles
Treatment of sick children
ORTCareseeking for pneumonia
Countdown 2008 Equity Analysis Group, Lancet 2008
• The overall mean = 57%– >80% in Turkmenistan and Peru– <30% in Ethiopia and Chad
• The coverage index improved by an average of 0.9 percentage point per year since the early 1990s - 2006– Based on 40 countries with more than one survey– Fastest improvements (>2 pp/year): Cambodia,
Mozambique, and Nepal– Declining index: Chad, Kenya, Zambia, and
Zimbabwe
Countdown 2008 Equity Analysis Group, Lancet 2008
Empirical data: levels and trends
Monitoring equity in Countdown
• What types stratification?– Wealth quintiles– Maternal education– Urban/rural– Gender– Ethnic groups– Etc
Photos: P Menzel
0 20 40 60 80 100
Coverage gap (% ) difference between the poorest (red) and least poor (blue) quintiles
Turkmenistan
South Africa
Brazil
I ndonesia
Zimbabwe
Congo Brazzaville
Tanzania
Lesotho
Gambia
Cambodia
Gabon
Cote d'I voire
Benin
Ghana
Cameroon
Guatemala
Rwanda
Guinea Bissau
Azerbaijan
Burkina Faso
Eritrea
Haiti
Mauritania
DRC
Pakistan
Nigeria
Lao PDR
Chad
Countdown 2008 Equity Analysis Group, Lancet 2008
Coverage gaps by country
Coverage index changes over time:levels and inequity
Table 1: Intervention areas, tracer indicators and additional indicators for coverage index.
Intervention area Tracer indicators Additional indicators Child vaccination DPT3/penta, measles BCG, polio, hepB
Maternity care ANC 4 or more visits, skilled birth attendance
ANC 1+ visit, institutional delivery, postnatal care
Family planning Unmet need for FP Contraceptive use
Treatment of sick children
Suspected pneumonia taken to health facil ity, diarrhoea with ORT
Suspected pneumonia treated with antibiotics, diarrhoea treated with ORS
Malaria Children sleeping under ITN; IPT during pregnancy
Fever treated with antimalarials/ACT; households with IRS
TB TB treatment success rate; TB case detection rate
HIV prevention Condom use at higher risk sex; PMTCT among HIV positive women; ART
Male circumcision rate
Cancer HPV vaccination; tobacco use*; cervical cancer screening
5 year survival rate (specific cancer); mammography
Cardiovascular diseases
Hypertension prevalence* Salt intake*; hypertension control follow-up visit; AMI survival; physical activity*
Mental health Injuries
Other NCD Asthma (re)admission rate; cataract surgery
* risk factors
Coverage index, based on intervention areas with tracer indicators within each areas
Summary points
29
• Coverage index works well in Countdown to ascertain levels, trends and inequity; good way to summarize multiple interventions
• Mean coverage better understood by policy makers than coverage gap for CD – gap measure makes sense for UHC?
• Dependence on surveys a disadvantage; if facility based coverage estimates are good they should be used increasingly, at least for some indicators
– Denominator problems: also with survey-based coverage rates
• UHC coverage index will need further methodological work, including the critical evidence based selection of core interventions
• Several aspects of the CountDown model deserve consideration for UHC monitoring, including country UHC monitoring, regular global analytical reports and country profiles
Acknowledgement
30
• Countdown to 2015 colleagues, especially Jennifer Bryce and Cesar Victora