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Innovations in Health Service Evaluation Techniques: Rafael Lozano


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This session examines new evaluation techniques to improve our understanding of how well health interventions accomplish their objectives.

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Innovations in Health Service Evaluation Techniques: Rafael Lozano

  1. 1. Assessing the Health Systems Performance of Mexican States Using Effective Coverage Professor Rafael Lozano Innovations in Health Service Evaluation Techniques 18th Annual Global Health Education Consortium Conference April 3 - 5, 2009
  2. 2. Outline <ul><li>Background </li></ul><ul><li>Data and Methods </li></ul><ul><ul><li>Selecting interventions and defining standards </li></ul></ul><ul><ul><li>Data collection and measurement strategies </li></ul></ul><ul><li>Results </li></ul><ul><ul><li>Specific interventions </li></ul></ul><ul><ul><li>Health system effective coverage </li></ul></ul><ul><li>Lessons learned </li></ul>
  3. 3. Sources: INEGI, CONAPO, DGIS, States 32 Municipalities 2,454 Localities 199,230 Population Millions 107.5 Males 52.8 Females 54.7 % Med Insured pop 73.0 % Non Insured pop 27.0 % Urban 78.5 % Rural 21.5 2009 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 0.4 0.6 0.8 1.0 1.2 100 90 80 70 60 50 40 30 20 10 0 Millions Male Female 18.2 millions 1st. - 3rd. generation 11.1 millions Born in Mexico 0.8 4.5 5.0 10.0 15.0 20.0 25.0 30.0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2006 Millions Mexican Origin Born in Mexico Migrants to USA
  4. 4. National Health System (2007) <ul><li>Fragmented : Insured Public Sector, Private y Non-insured </li></ul><ul><li>Decentralized: the process started in 1982 and concluded in 1996 </li></ul><ul><li>Financial unbalances: Decreasing since 2004 </li></ul>534.2 218** 115** 1,664 Total (absolute) 1,000.0 29.5 30.2 29.7*** Private 216.8 Seguro Popular (Health Reform) 910.0 3.2 3.2 5.0 Others 231.9 7.7 5.9 6.4 ISSSTE 324.8 25.0 27.6 16.3 IMSS 325.6 36.0 36.5 27.9 Medical Insurance 87.9 34.5 33.3 42.4 No Medical Insurance Health Expenses per capita USD Physicians % Beds % Hospitals % * Millions ** thousands *** Includes Hospitals over 15 beds. Private Sector has more than 2.5 thousand small hospitals Source: Sistema Nacional de Información en Salud, DGIS 2009 106* 2.9 25.5 1.5 7.5 35.8 73.2 26.8 Population Affiliated %
  5. 5. Background <ul><li>IV. How do we measured the advances </li></ul><ul><li>Accountability as part of the democratic process </li></ul><ul><li>- Outcomes measurement and Health System performance assessment </li></ul><ul><li>Accountability </li></ul>La democratización de la salud en México Hacia un sistema universal de salud Programa Nacional de Salud 2001-2006
  6. 6. <ul><li>Art 87: Formula for resource allocation by state </li></ul><ul><ul><li>Number of affiliated families </li></ul></ul><ul><ul><li>Health needs (under-five mortality  DALYs) </li></ul></ul><ul><ul><li>State effort (local investments) </li></ul></ul><ul><ul><li>Health system performance (effective coverage) </li></ul></ul>Background <ul><li>Art 23: Attributions to the General Direction of Performance Evaluation </li></ul><ul><ul><li>To evaluate the HSP at national and subnational levels…health outcomes, responsiveness and fair financing… </li></ul></ul><ul><ul><li>To report annually the results for accountability purposes </li></ul></ul>REGLAMENTO INTERIOR DE LA SECRETARIA DE SALUD Ultima Reforma DOF 29-11-2006
  7. 7. Background Objectives Functions Responsiveness Health Fear Financial contribution Stewardship Generation Resource Delivering Services Financing Effective Coverage
  8. 8. Effective coverage is the synthesis of three analytical approaches in the study of “coverage” of health services Sociological Studies about access to health services, utilization, identification of barriers, etc. Economics Studies about health care demand concerning prices, quality, distance, etc . Public health Studies of the proportion of the population that receives an intervention (coverage)
  9. 9. What is Effective Coverage? <ul><li>Intervention Effective Coverage </li></ul><ul><ul><li>Fraction of the potential health gain of an intervention that is being delivered to a population </li></ul></ul><ul><ul><li>Measure: </li></ul></ul><ul><ul><ul><li>the population in need (N) of the intervention; </li></ul></ul></ul><ul><ul><ul><li>utilization (U) of the intervention amongst the population in need; and </li></ul></ul></ul><ul><ul><ul><li>the quality (Q) of the intervention, measured as the fraction of potential health gain realized, being delivered in those who receive the intervention </li></ul></ul></ul><ul><li>EC ij = Q ij U ij | N ij =1 </li></ul><ul><ul><li>Incorporates quality into the notion of coverage – utilization of an intervention conditional on need </li></ul></ul><ul><li>Health system effective coverage </li></ul><ul><ul><li>Fraction of the potential health gain that the system is delivering through the full range of health services, given the set of health needs the population faces </li></ul></ul>
  10. 10. Outline <ul><li>Background </li></ul><ul><li>Data and Methods </li></ul><ul><ul><li>Selecting interventions and defining standards </li></ul></ul><ul><ul><li>Data collection </li></ul></ul><ul><ul><li>Measurement strategies </li></ul></ul><ul><li>Results </li></ul><ul><ul><li>Specific interventions </li></ul></ul><ul><ul><li>Health system effective coverage </li></ul></ul><ul><li>Lessons learned </li></ul>
  11. 11. Selecting Interventions, Norms and Standards <ul><li>Select a set of priority interventions to measure the effective coverage for, as a proxy of health system effective coverage </li></ul><ul><ul><li>Not feasible to measure effective coverage for all interventions </li></ul></ul><ul><ul><li>What are the criteria? </li></ul></ul><ul><ul><ul><li>Total health gain </li></ul></ul></ul><ul><ul><ul><li>Affordability </li></ul></ul></ul><ul><ul><ul><li>Impact on inequalities </li></ul></ul></ul><ul><ul><li>Specific to region to account for differential epidemiology, resources etc </li></ul></ul><ul><ul><li>Possible disadvantage: funders/providers may focus solely on those interventions </li></ul></ul><ul><li>Establish standardized definitions of need for each intervention </li></ul><ul><ul><li>Required to guide measurement strategies </li></ul></ul><ul><ul><li>Need for cholesterol lowering medication, threshold based on: </li></ul></ul><ul><ul><ul><li>Total cholesterol </li></ul></ul></ul><ul><ul><ul><li>LDL cholesterol </li></ul></ul></ul><ul><ul><ul><li>Absolute risk of cardiovascular disease </li></ul></ul></ul>
  12. 12. Establish standardized definitions of need, use and quality for each selected intervention
  13. 13. Establish standardized definitions of need, use and quality for each selected intervention Intervention Population in Need Utilization Quality Breast Cancer Screening women aged 40-69 having a mammography within the past year not available Cervical Cancer Screening women aged 25-64 having a pap test within the past year not available Treatment of Vision Disorders adults older than 20 years of age who report near or far visual impairment or wear glasses/contacts use glasses or contacts report no near or far visual impairment when wearing glasses or contacts Glycemic Control in Diabetics fasting plasma glucose or FPG estimated from casual plasma glucose higher than or equal to 126 mg/dl self-reported use of oral hypoglycemics or insulin reduction in fasting plasma glucose compared to treatment targets Treatment of Hypertension adults older than 20 years of age with systolic blood pressure equal or greater than 140mmHg self-reported use of anti-hypertensives reduction in SBP compared to treatment targets Treatment of High Cholesterol adults older than 20 years of age with total cholesterol equal to or greater than 200mg/dl self-reported medication for cholesterol reduction in total cholesterol compared to treatment targets
  14. 14. Interventions selected <ul><ul><li>Immunization against Measles, DPT, BCG (children) and Flu for adults </li></ul></ul><ul><ul><li>Antenatal Care, Skill Birth Attendant </li></ul></ul><ul><ul><li>Screening for Cervical and Breast cancer </li></ul></ul><ul><ul><li>Services delivered to premature newborns </li></ul></ul><ul><ul><li>Treatment of diarrhea and acute respiratory infections </li></ul></ul><ul><ul><li>Visual disorders correction (adults) </li></ul></ul><ul><ul><li>Treatment of hypertension and hypercholesterolemia </li></ul></ul>
  15. 15. Measuring effective coverage in Mexico <ul><li>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) </li></ul><ul><li>The information sources basically come from the ENSANUT 2005, administrative registries and vital statistics </li></ul><ul><li>Effective coverage has been measured for 7 interventions and crude coverage for other 7 interventions </li></ul><ul><li>Effective coverage has been estimated by state, by health care provider and by level of household wealth </li></ul><ul><li>Also a composite measure of effective coverage was estimated </li></ul>
  16. 16. Outline <ul><li>Background </li></ul><ul><li>Data and Methods </li></ul><ul><ul><li>Selecting interventions and defining standards </li></ul></ul><ul><ul><li>Data collection and measurement strategies </li></ul></ul><ul><li>Results </li></ul><ul><ul><li>Specific interventions </li></ul></ul><ul><ul><li>Health system effective coverage </li></ul></ul><ul><li>Lessons learned </li></ul>
  17. 17. Coverage of Skilled birth attendant for Mexican states, 2005 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Chis Oax Gro Tamp Yuc Ver Qroo Tab Camp Mor BC Col EUM Mex Slp Pue Sin Chih Nay Qro Hgo Dgo Son Zac Tlax Mich Coah NL Ags Jal Gto Bcs DF
  18. 18. Coverage of Antenatal Care for Mexican states, 2005
  19. 19. Coverage of antenatal care and Skill Birth Attendance by wellbeing quintiles, México 2005 0% 20% 40% 60% 80% 100% 1 2 3 4 5 Coverage Antenatal Care 0% 20% 40% 60% 80% 100% 1 2 3 4 5 Coverage Skill Birth Attendant Households wealth quintiles Low High Low High Source: ENSANUT 2005
  20. 20. Crude and effective coverage of treatment for hypertension in Mexican states 2005
  21. 21. Prevalence and Effective coverage of treatment for hypertension in Mexican states 2005 Prevalence of population 20years+ Effect. Coverage (HTA controlled) 30-36% 26.4-29.9% 24-26.3% 21.3-23.9% National Prevalence 20.5% (20 years+) 16 millions
  22. 22. Hypertension Under Control, 2000-2005 2000 2005 0% 5% 10% 15% 20% No Med Insured SP insured Private Social Security Probability of Being Treated on Antihypertensive Medication by Insurance Type
  23. 23. Coverage for cervical and Breast cancer screening in Mexico by household wealth, 2005 Households wealth quintiles Cervical Cancer Screening Breast Cancer Screening 0% 10% 20% 30% 40% 50% 60% 1 2 3 4 5 2000 2005 0% 5% 10% 15% 20% 25% 30% 35% 1 2 3 4 5 2000 2005
  24. 24. Composite Index of Effective Coverage
  25. 25. 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
  26. 26. Composite effective coverage (14 interventions) for 2005by state, versus the log of public health expenditure per capita.
  27. 27. 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.
  28. 28. Outline <ul><li>Background </li></ul><ul><li>Data and Methods </li></ul><ul><ul><li>Selecting interventions and defining standards </li></ul></ul><ul><ul><li>Data collection and measurement strategies </li></ul></ul><ul><li>Results </li></ul><ul><ul><li>Specific interventions </li></ul></ul><ul><ul><li>Health system effective coverage </li></ul></ul><ul><li>Lessons learned </li></ul>
  29. 29. Lessons for Mexico <ul><li>Mexico is the first country to fully implement the recommendation to measuring EC at subnational level </li></ul><ul><li>EC allows us to say than Mexico has two health systems, one for Maternal and Infant health needs and other for Non Communicable diseases and injuries </li></ul><ul><li>If 82% of the Burden of Disease is due to Non communicable diseases, is necessary to redirection the health priorities </li></ul><ul><li>The physical access to health facilities is not a major problem </li></ul><ul><li>The relation between public health spending percapita and EC highlights the importance of raising levels of spending per capita in the disadvantaged states </li></ul>
  30. 30. Implications for the Mexican Health Information System <ul><li>It is important recognize that this type of contribution to the health reform can be made thanks to the Health Information System that exists in the country (the system of health surveys, administrative records and vital statistics), however is necessary </li></ul><ul><li>More attention in future to measuring quality of intervention delivery. </li></ul><ul><li>Careful attention in developing better measures of effective coverage , for example Diabetes. </li></ul><ul><li>Further work is needed to characterize the biases in administrative data for measuring effective coverage of some interventions. </li></ul><ul><li>A comprehensive information's system needs to harmonize data collection for certain interventions across all institutions of public sector and even private. </li></ul>
  31. 31. Global Lessons <ul><li>Updating the philosophy of HS </li></ul><ul><ul><li>How much health gains is delivering the HS? </li></ul></ul><ul><li>Another way to measure access to health facilities </li></ul><ul><li>EC shifts the focus to achievements </li></ul><ul><li>Strengthening the economic analysis of HS resources </li></ul><ul><li>Affects the four HS functions </li></ul>
  32. 32. Global Lessons <ul><li>How should other countries define their set of interventions for monitoring effective coverage? </li></ul><ul><li>What institution has the independence, credibility, resources and technical competence to undertake this work? </li></ul><ul><li>What countries should do with the low coverage of those interventions related with Non communicable disease? </li></ul>