Benchmarking Performance of Mexican States Using Effective Coverage

1. Benchmarking Performance of Mexican States Using Effective Coverage Rafael Lozano, Patricia Soliz, Emmanuela Gakidou, Jesse Abbott-Klafter, Dennis M Feehan, Cecilia Vidal, Juan Pablo Ortiz, Christopher JL Murray Health System Metrics Glion, Switzerland September 28-29 2006

2. Outline • Background • Effective coverage at sub-national level • Selecting interventions • Measurement strategies • Results • Selected interventions • Health system effective coverage • Lessons learned

3. Background • National Health Program 2001-2006 • Goals, Strategies and Activities • Health Reform in Mexico 2004-2010 • Formula for resource allocation • WHO HSPA framework 2000 and new versions

4. Information and Local Capacity • National Health surveys • World Health Survey • National survey of health system performance (2002) • Administrative records • Links from the MOH with HIGH and NIPH • Publications, workshops

5. Population Million 106.5 Mexico 2005 Males 51.8 85 + Females 52.4 80 a 84 % with health insurance 56.2 75 a 79 Males Females 70 a 74 % without health insurance 43.8 65 a 69 % Urban Areas 74.7 60 a 64 % Rural Areas 25.3 55 a 59 50 a 54 45 a 49 40 a 44 35 a 39 30 a 34 25 a 29 20 a 24 15 a 19 10 a 14 5 a 9 0-4 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 Mexico 2005 States 32 Counties 2.4 thousands Localities 199 thousands

6. Health Change in Mexico Age pattern Causes of death transition 100% 100% 80% 80% 60% 60% 40% 40% 20% 20% 0% 0% 1950 1960 1970 1980 1990 2000 2010 2025 1950 1960 1970 1980 1990 2000 2010 2025 Communicable Non Communicable Injuries 0-14 15-65 65+

7. Mexico Health System (2005) Popu- Lation % Beds % Physicians % Expenditure per Percapita USD Hospitals % • Fragmented • Insured Inst, Non Insured Inst, Private • Decentralized • Since 80s • Financial Unbalances No medical insurance 43.8 35.5 31.4 29.7 87.9 With medical Insurance 56.2 38.0 38.3 30.5 325.6 IMSS 35.8 23.1 26.8 29.9 324.8 ISSSTE 7.5 7.0 6.2 7.0 231.9 Popular Insurance 8.5 216.8 Others 1.5 7.9 5.2 3.6 910.0 Private 2.8 26.5 30.4 29.8 1,000.0 Total (absolute) 106* 1,511 109** 218** 534.2 * millions, ** thousands

8. Outline • Background • Effective coverage at sub-national level • Selecting interventions • Measurement strategies • Results • Selected interventions • Health system effective coverage • Lessons learned

9. Public health Sociological Studies of the proportion of the population that receives an intervention Studies about access to health services, utilization, identification of barriers Economics Studies about health care demand concerning prices, quality, distance, etc. Effective coverage is the synthesis of three analytical approaches in the study of “coverage” of health services

10. Effective Coverage • the fraction of potential health gain that can be delivered through an intervention by the health system that is actually delivered Defining the set of interventions • affordability, • total population health gain • impact on health inequalities. • whether a measurement strategy for the intervention can be developed Steps for EC Measurement • How do we identify the group who needs an intervention? • How do we identify those who need an intervention that received one? • How do we measure quality of the intervention delivered?

11. Table 1: Selected interventions for the measurement of EC in Mexico Normative One or several symptoms Biological markers

12. Measuring effective coverage in Mexico • This exercise was carried out by the Ministry of Health (General Direction of Health Information), the National Institute of Public Health and Harvard University (HIGH) • The information sources basically come from the ENSA 2000, ENED 2002, ENSANUT 2005-06, administrative registries and vital statistics • Effective coverage has been measured for 8 interventions and coverage for 18 interventions • Effective coverage has been estimated by state but not by health care provider • A composite measure of effective coverage was estimated • The precision on each of the indicators vary according to the quality of the data source

13. Outline • Background • Effective coverage at sub-national level • Selecting interventions • Measurement strategies • Results • Selected interventions • Health system effective coverage • Lessons learned

14. Visual Impairment correction • Definition • Effective coverage for visual impairment is defined as the proportion of adults over the age of 20 with visual impairments that have glasses or contacts that solve their vision problems. • How was need estimated? • Need for correction of visual impairments is measured in the ENSANut 2005-06 by self-reports of difficulties on two items in the survey. This module of the survey was only applied to respondents over the age of 20 and included two questions on difficulties with vision. All individuals responding that they had any visual difficulties were included as needing correction. • How was utilization estimated? • Utilization is calculated using self-reported use of glasses or contacts. • How was quality estimated? • Quality has been estimated using the items in ENSANut 2005-06 on difficulties with near and far-vision using glasses or contacts. Any individual who reports no problems on both questions in the survey is counted as having effective coverage. We have not weighted the measure by the magnitude of problems reported so this is not a direct measure of the fraction of health gain delivered by the intervention. This measure also suffers from all the comparability problems that plague any measure of self-reported functional health.

15. Crude and effective coverage* of visual impairment correction for Mexican states and Distrito Federal, 2005-2006. *95% confidence intervals

16. Services delivered to premature newborns • Definition • The fraction of the maximum possible health gain that can be delivered to moderately premature newborns that is actually delivered. The maximum health gain was constructed as the difference between the expected upper and lower bound for death rates conditional on gestational age and birth weight. • How was need estimated? • All moderately premature newborns in Mexico; moderately premature has been defined as gestational age between 28 and 36 weeks and birth weight less than 3500g. • How was utilization estimated? • We have used the same dataset to define utilization of hospital services for premature newborns as we have used for need. • How was quality estimated? • The difference in the observed mortality rate among premature newborns compared to the maximum and minimum mortality rates conditional on gestational age and birth weight that could be observed. • Maximum mortality rates has been constructed from the neonatal mortality rates, conditional on birth weight and gestational age, recorded in the US in 1950 (2): in 1950, effective interventions for premature newborns were not yet available at that time so this represents a reasonable approximation of no care. • The lower bound for death rates was estimated based on a regression analysis of the standard of care for premature newborns conditional on gestational age and birth weight in the states of Massachusetts, New York, and New Jersey in 2000-2002, which have the lowest conditional mortality rates in the US.

17. Effective coverage of services delivered to premature newborns in Ministry of Health hospitals and 95% confidence intervals, 2004-2005 by Mexican state.

18. Treatment of Hypertension • Definition • The ratio of actual systolic blood pressure reduction from treatment of hypertension to potential blood pressure reduction. • How was need estimated? • In the estimation of effective coverage, need of treatment is defined as a level of blood pressure equal or above a threshold of 140 mmHg. The information on levels of blood pressure is taken from the ENSANut 2005-06 survey, which records for each individual aged 20 and above two measurements of systolic blood pressure (SBP), taken five minutes apart. The prevalence of the condition is estimated using an average of the two measurements. • How was utilization estimated? • The ENSANut 2005-06 provides state representative data for the analysis of blood pressure including self-reported information on treatment with medication. An individual is considered to be on treatment for hypertension if he or she reports currently taking medication to control his or her level of blood pressure. • How was quality estimated? • In the first stage of the analysis, we use logistic regression to model the probability of a respondent reporting being on anti-hypertensives as a function of age, sex, bmi, speaking an indigenous language, household wealth, and level of education, in addition to our two instruments: insurance status and the crude coverage of hypertension in the respondent’s community. Results of the first-stage IV analysis show that both instruments are highly predictive of the probability of treatment: the area under the model’s ROC curve is 0.84. • In the second stage analysis we use linear-normal regression to model blood pressure as a function of the predicted probability of being on antihypertensives, as well as the set of non-instrumental covariates used in the first stage. The second stage results suggest a treatment effect of 11mmHg.

19. Crude and effective coverage and 95% confidence intervals of treatment for hypertension in Mexican states and Distrito Federal, 2005-2006.

20. Coverage of Cervical Cancer Screening, México 2000 -2005

21. Coverage of Cervical Cancer Screening, México 2000 -2005 Insurance Income Quintile

22. Constructing Effective Coverage Composites • following the formal definition of effective coverage, each intervention could be combined in proportion to the average health gain it delivers to the population; • preference weights can be derived from revealed choices in the marketplace or from survey responses; • arbitrary weights such as simple averages or other weights can be used; • one can assume that each indicator is an imperfect measure of an underlying unobserved construct, health system effective coverage, and use latent variable techniques such as factor analysis or variants of probits and logits.

23. 60% 50% 40% 30% 20% 10% 0% DF Jal Camp Gto Hgo Dgo Nay Tab Mex Coah Col Yuc Ags BC Qroo Tamp NL Zac Sin Slp Qro Pue Chih Son Tlax Gro Chis Mor Oax Mich Bcs Ver EUM Composite Index of Effective Coverage

24. Composite effective coverage (14 interventions), maternal and child health intervention coverage (8 interventions) and other adult interventions coverage (6 interventions) by household wealth quintile, Mexico 2005

25. Composite effective coverage (14 interventions) for 2005by state, versus the log of public health expenditure per capita.

26. Change in effective coverage for 8 interventions measured in 2000 that are strictly comparable to 8 interventions measured in 2005, by state, compared to the percent increase in public spending per capita over the same time period. respiratory infection, diarrhea, cervical and breast cancer screening, skilled birth attendance, hypertension, services delivered to premature newborns, and antenatal care.

27. Outline • Background • Effective coverage at sub-national level • Selecting interventions • Measurement strategies • Results • Selected interventions • Health system effective coverage • Lessons learned

28. Lessons for Mexico • Mexico is the first country to fully implement the recommendation to measuring EC at subnational level • The relation between public health spending percapita and EC highlights the importance of raising levels of spending per capita in the disadvantaged states • EC allows us to say than Mexico has two health systems, one for MIC and other for Non Communicable diseases and injuries • Improve HIS and build local capacity (investment)

29. Implications for the Mexican Health Information System • More attention in future to measuring quality of intervention delivery. • Examination surveys produce hard endpoints in which to anchor the analysis. • Careful attention in developing better measures of effective coverage, for example Diabetes. • Further work is needed to characterize the biases in administrative data for measuring effective coverage of some interventions. • A comprehensive information's system needs to harmonize data collection for certain interventions across all institutions of public sector and even private. • Because of the potential of pharmacological strategies for hypertension, cholesterol and possibly blood sugar (diabetes), prospective registries of treatment impact should be developed.

30. Global Lessons • Updating the philosophy of HS • How much health gains is delivering the HS? • Another way to measure access to health facilities • EC shifts the focus to achievements • Strengthening the economic analysis of HS resources • Affects the four HS functions • To revise the scope of the agenda: MDG+ framework (focusing in monitoring EC of interventions for non communicable and injuries)