Measuring / Monitoring Progress towards UHC

1. Measuring /Monitoring Progress towards UHC V R Muraleedharan, IIT Madras 3 October 2014

2. A Key question in public policy (Development Programme intervention) • How well are the benefits of public spending (on health care) distributed across socio-economic groups? • Are the poor getting their “fair share” of the benefits of public spending (on health care)?

3. Utilization: TN (Girija et al. 2011)

4. Utilization: Orissa (girja et al 2011)

5. What to measure? How do we assess the progress of NRHM? What are its “declared objectives”? : Provide “accessible, affordable, and quality of care to rural population”.

6. Access? Utilization? • Definitions are important (What do we want to measure, observe?) • What can be Measured? (proxies) • Methods of measurement (Quantitative/Qualitative, surveys, interviews, observational. etc.) • Frequency and duration (of observations) • Who is observing? • Analysis and presentation • Evaluation of evaluations (peer-review) • Knowledge/Research uptake “strategy”?

8. UHC? • What to provide? How much? • How to provide? • For whom? • Who decides these questions? And by what process? • How do we measure /assess progress with respect to these above questions?

12. IS there An Ideal assessment Frame-work? • Framework is important • Six pillars (health systems functions) • Performance Criteria • Ref: (Health systems 20/20. 2012. The Health System Assessment Approach: A how-to manual version 2.0 (www.healthsystemassessment.org)

13. Building blocks interactions(www.healthsystemassessment.org)

14. Key Indicators: Financing(www.healthsystemassessment.org) • THE as % of GDP • Per capital total health expenditure • Govt. expd on health as % of THE • External resources as % of THE • OOPs as % of THE • Population coverage of health insurance • Multiple/disaggregated indicators should be developed (rural/urban/service oriented, etc)

15. Performance indicators for Health Financing (HSAA, 2012) • Equity (OOPs as % of THE; policies for user-fees, informal payment, etc) • Efficiency (Process of MoH budget formulation, local level spending and institutional capacity, contracting mechanisms; etc) • Access (user fees, informal payment, population coverage of health insurance, etc) • Quality (govt. spending as % THE, contracting mechanisms, • Sustainability (budget allocations, level of decentralisation, process of budget allocation, etc) • Recent PoE/IEG study, NRHM, 2012) covers a range of issues; long way to go as per “Six Pillars/Performance Criteria” framework

16. Key Indicators: HRH(www.healthsystemassessment.org) • Current HRH situation • Policy and Planning • HRH management system • Financing of HRH • Education and Training • Leadership of entire HR

17. Concluding remarks Cadres of researchers • Who can do what? (academic/university based; advocacy action research; Think-Tanks (NHSRC, IPH, within Govt Evaluation cells; etc) Short term, medium term, long term research) • “Implementers and evaluators” (what do they say?) Implementation Research: • “ Implementation Research” (focus on processes, encourage the open-box approach, rather than outcomes/outputs alone. “Eg: “How do we assess whether an incentive has worked?” Should we merely use the performance and make conclusions? • Ssengooba F. et al (2012) “why performance based contracting failed in Uganda? An open box evaluation of a complex health system intervention” social science and medicine 75 (2012)

18. Concluding remarks • Building stronger bridges between implementers and evaluators (Mills, et al 2012, Chapter 16) • Researchers/Evaluations from Design stage rather than at the final stage of evaluation • Insist on Publication of Evaluation Research: Per-reviewed processes are a must….they should be viewed as a part of the democratic process….”in the knowledge creation and knowledge uptake process”…..

23. Thank you