Benchmarks of Fairness Workshop Agenda

1. Benchmarks of Fairness WorkshopAgenda Sviavonga, Zambia June 11-13, 2003

5. Benchmarks of Fairness:A policy tool for developing countries Norman Daniels June, 2003 Zambia

6. Norman Daniels ndaniels@hsph.harvard.edu Dept. Population and International Health, HSPH

7. Development of BMs • 1993 Clinton Task Force • 1996 Benchmarks of Fairness OUP • 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, Sri Lanka, Yunnan, Bangladesh, Zambia

8. Some Common Concerns about HS Trends • Rising Costs • Epidemiological Transition • Privatization and structural reform • External pressures, transitional economies • “introduce new resources” • BUT: undermine public resources • “avoid state bureaucracy” • BUT: strong state needed to regulate markets • Lack of focus on equity, accountability: no integration • In Grip of Ideology of Market • Lack of Satisfactory Results

9. 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 The Adapted Benchmarks

10. 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

11. Equity • Equality • Vs Equity • Benefit according to need • Burden according to ability to pay

12. Efficiency • Value for money • Vs equity • Promoting equity

13. Accountability • Responsible to: • Patient • Institution • public • Agent • Responsible for • Act or outcome

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

15. Some evaluation approaches • Specific reseach on reform effects (e.g. Bossert on decentralization, Hsiao on financing outcomes) • Monitoring of reform process (e.g. PAHO monitoring project) • WHO Framework (index for cross country performance comparisons, including focus on equity, efficiency, responsiveness) • Policy development approaches: Reich, Roberts, Berman -- new book based on World Bank project to get reform efforts right, including value clarification

16. WHO BM Scope Cross national Nat, subnat Objective Current perform Reform eval Purpose Motivate Deliberate Product Index, ranks Scores Who uses National pol mk Various Requires Good info Info, tr. people Problems Inform change? Subjectivity? Overlap Move to reforms complementary WHO Framework vs BM

17. Key Features of BM • Country Specific: national, subnational • Integrates Equity, Efficiency, Accountability • Evidence Based (Objectivity) • Pragmatic • adapted locally to purposes, evidence • focus on improvement • Improves Deliberative Capacity • Complements other approaches

18. EG complements BM Strong intersectoral focus (Chile, Burkina Faso, Kenya) Strong focus on path from info collection to evidence based interventions,w. accountability Strategies for sensitive info Good public private collaborations BM complements EG Useful for G’s focusing on health care systems and budgeting as in Zambia, Zimbabwe, Uganda, S.A./Cape Town Help G’s to prioritize issues and focus on advocacy campaigns within G’s Further tool for advocacy within G’s EG and BM Interaction

19. 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 inequities • Degree reform engages in active intersectoral effort

20. 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

21. 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

22. B4: Comprehensiveness of benefits and tiering • All effective and needed services deemed affordable by all needed providers, no categorical exclusions • Reform reduces tiering and achieves more uniform quality, integrates services to all

23. B5: Equitable financing • Financing by ability to pay • If tax based scheme: how progressive (by population subgroup), how much reliance on cash payments (by subgroup) • If premium bases scheme: community rated? Reliance on cash payments?

24. B6: Efficacy, efficiency and quality of health care • 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 interventions • Measures to improve quality • Regular assessment, accreditation, training

25. B7: Administrative efficiency • Minimize administrative overhead • Cost-reducing purchasing • Minimize cost shifting • Minimize abuse and fraud and inappropriate incentives

26. 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)

27. B9: Patient and Provider autonomy • Degree of consumer choice • Primary care providers, specialists, alternative providers, procedures • Degree of practitioner autonomy

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

29. 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

30. 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 rules • Further revision in light of field testing

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

32. 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

33. Structure of Scoring Rule:I • Relative to scale from -5 to +5 with 0 as status quo or point of reform • If there is only one indicator for criterion and it is outcome indicator: • Estimate ideal outcome for this indicator, e.g., 100% coverage for a population group for clean water or vaccination • Specify baseline value -- e.g., 60% • Divide gap between baseline into proportions of scale and assign score value to indicator outcomes

34. Structure of scoring Rule:II If only one indicator and it is process and qualitative; e.g. to measure transparency we count public reports issued for performance of pharmacies or district hospitals Could count % of such units issuing public reports -- then scoring might work as in previous case • May need to combine this indicator with another measuring public access to the report (was it really available on request, did anyone request it, did community or advocacy group request it, or actually use it

35. What about disagreements? • Won’t different groups using bm’s come up with different scoring rules, different results? • Yes, but specification of evidence base provides basis for deliberation about disagreements • Won’t different groups using same instrument have come disagreements about evaluations? • Yes, but specificity of evidence base provides basis for resolving dispute?

36. Perfect information? • Won’t benchmarks reflect only part of truth about situation with policies under analysis? • Better to seek comprehensive household survey to get complete representative view? • Settle for less perfect info but have a basis for deliberation about disagreements - but requires clarity about evidence base

37. Information Plus Process • Many approaches aim to give excellent information input but leave process of deliberation unaffected • Benchmarks aim to improve process of deliberation itself • Adaptation that includes developing evidence base is training in what to look for when monitoring and evaluating and how to derive conclusions about reform from that • Improvement can take place at any level -- official policy makers, institutions doing implementation and lower level planning, community groups assessing effects

38. Cameroon • MoH supports evaluation officially • Subnational -- district level • Medical Student rotation -- training, fieldwork • Baseline, then repeats for monitoring, evaluation • evidence base: complex, capacity building, revisable, limited resources

39. Cameroon constraints on indicators: illustrating compromises • Absence of survey data • Student investigators • District level sources • Risks to students

49. Cameroon Results • Data from 8 districts, first group of students, analyzed, May ‘03; data quality so far good • Data from some bmks easier to collect than others; waiting results from other districts and students • Further steps: faculty workshop to refine criteria, national workshop to present and adopt indicators, nationwide implementation as framework, use by DMOs as management tool

50. Current Projects: I • Phase 2: • Thailand--Supasit project-- RF-- report drafted; electronic version soon available • Pakistan--Khan project--RF--just beginning • Mexico--Gomez Dantes--Mexican funding--publication in prep, available electronically • Portugal--Portuguese funding • Phase 1+: Vietnam-- MoH proposal-- seeking RF • Phase 1: (various stages) • Underway for 1 yr or less months: • Cameroon-- preliminary report available • Nicaragua, Ecuador, Guatemala : indicators selected in Ecuador, Guatemala, field testing this summer • Kenya (informal, Bryant)