Benchmarks of Fairness Workshop Agenda

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Benchmarks of Fairness WorkshopAgenda

• Sviavonga, Zambia
• June 11-13, 2003

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Benchmarks of FairnessA policy tool for
developing countries

• Norman Daniels
• June, 2003
• Zambia

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Norman Daniels

• ndaniels_at_hsph.harvard.edu
• Dept. Population and International Health, HSPH

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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 PhaseMexico, Portugal,
  Pakistan, Thailand Vietnam Cameroon, Ecuador,
  Nicaragua, Guatemala, Chile, Sri Lanka, Yunnan,
  Bangladesh, Zambia

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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

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The Adapted Benchmarks

• 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

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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

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Equity

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

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Efficiency

• Value for money
• Vs equity
• Promoting equity

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Accountability

• Responsible to
• Patient
• Institution
• public
• Agent
• Responsible for
• Act or outcome

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Structure of BMs

• B1-9 Main Goals
• Criteria -- Key aspects
• Sub criteria-- main means or elements
• Evidence Base Evaluation
• Indicators
• Scoring Rules

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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

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WHO Framework vs BM
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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

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EG and BM Interaction

• 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 Gs focusing on health care systems
  and budgeting as in Zambia, Zimbabwe, Uganda,
  S.A./Cape Town
• Help Gs to prioritize issues and focus on
  advocacy campaigns within Gs
• Further tool for advocacy within Gs

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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

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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

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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

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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

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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?

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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

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B7 Administrative efficiency

• Minimize administrative overhead
• Cost-reducing purchasing
• Minimize cost shifting
• Minimize abuse and fraud and inappropriate
  incentives

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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)

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B9 Patient and Provider autonomy

• Degree of consumer choice
• Primary care providers, specialists, alternative
  providers, procedures
• Degree of practitioner autonomy

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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

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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

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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

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

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Structure of Scoring RuleI

• 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

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Structure of scoring RuleII

• 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

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What about disagreements?

• Wont different groups using bms come up with
  different scoring rules, different results?
• Yes, but specification of evidence base provides
  basis for deliberation about disagreements
• Wont different groups using same instrument have
  come disagreements about evaluations?
• Yes, but specificity of evidence base provides
  basis for resolving dispute?

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Perfect information?

• Wont 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

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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

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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

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Cameroon constraints on indicators illustrating
compromises

• Absence of survey data
• Student investigators
• District level sources
• Risks to students

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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

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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)

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Current Projects II

• Phase 1 Work
• Recently underway-- initial workshop held, plan
  developed, working group carrying out adaptation,
  mix of MoH, NGO, academics, varying degrees
  approval from MoH
• Chile -- November 2002 EG collab
• Bangladesh-- January 2003 EG collab
• Sri Lanka - December 2003 some WHO country
  support
• Kunming- Jan 2003 seeking WHO country support
• Planning Stage
• African sites--Zambia, South Africa (June 2003,
  EG collab), Zimbabwe, Botswana, Nigeria,
  Tanzania, Uganda

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Project Needs

• Longer term support for regional coordination
  (Asia, Africa, Latin America)
• Country level support for second phase projects
• Midterm support for web page, training manual (to
  be in place by end of 2003 with RF support)