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1996 Benchmarks of Fairness for Health Care Reform Oxford University Press. ... Guatemala, Cameroon: team evaluation based on indicators, scoring rules ...

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Benchmarks of Fairness for Health Sector Reform in Developing Countries: Overview and Latin American Applications

Norman Daniels


Santiago, Chile, Jan 16, 2004

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Historical Development of the Benchmarks

  • 1993 Clinton Task Force

  • 1996 Benchmarks of Fairness for Health Care Reform – Oxford University Press.

  • 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, Yunnan (China), Sri Lanka, Bangladesh, Zambia

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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

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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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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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Cross national

Nat, subnat


Current perform

Reform eval





Index, ranks


Who uses

National pol mk



Good info

Info, tr. people


Inform change?



Move to reforms


WHO Framework vs BM

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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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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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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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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

-50 +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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Thailand: survey of various groups judging based on discussion of evidence

Strengths: range of views, involvement of larger groups

Weakness: vaguer basis for judgment?

Guatemala, Cameroon: team evaluation based on indicators, scoring rules

Strengths: clarity about evidence base for evaluation

Weakness: trained team, narrow input

Two approaches to evidence

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Guatemala, Ecuador:Stage 1: Theoretical adaptation

  • Conceptualizing public health

    • The set of actions implemented through a health care system which includes personal, collective, environmental and health promotion interventions. The delivery of services can be through public or private providers (with public funding) and its design and evaluation concerns providers, financers (public and private) and regulators.

  • Output:

    • Working document with specific version adapted to the context of Guatemala and Ecuador

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Defined by Daniels et al (2000)

Benchmark I: Intersectorial Public Health

Benchmark II: Financial barriers to equitable access

Benchmark III: Non financial barriers to access

Benchmark IV: Comprehensiveness of benefits and tiering

Benchmark V: Equitable financing

Benchmark VI: Efficacy, efficiency and quality of care

Benchmark VII: Administrative efficiency

Benchmark VIII: Democratic accountability and empowerment

Benchmark IX: Patient and provider autonomy

Adaptation to Public Health

Benchmark I: Intersectorial public health

Benchmark II: Universal access to public health interventions

Preventive services, Curative services

Social protection against catastrophic illness

Reduction of financial barriers

Reduction non-financial barriers.

Benchmark III: Equitable and sustainable financing

Equity in health financing

Sustainability in public financing

Benchmark IV: Ensuring the delivery of effective public health services

Technical quality (standard treatment guidelines)

Efficiency (relation between inputs and outputs)

User satisfaction

Benchmark V: Accountability

Social participation, community involvement in the evaluation and monitoring of inequities in health care delivery and resource allocation

Adapted benchmarks

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Stage 2: Data collection and data analysis tools

  • Intervention level: Province/Department

    • Decentralization transferred policy-implementing responsibilities and resources to the sub-national level. Development of tools and field testing follows from the provincial to the municipal level.

  • Outputs:

    • Data collection: questionnaires (quantitative & qualitative) to assess criteria and indicators for each benchmark

    • Data analysis: index to assess inequities, health expenditures analysis through proxies (drug consumption), excel database.

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Stage 3: Field testing

  • Outputs:

    • Data collection tools for benchmarks I to V.

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Examples of application

  • Starting with an analysis of inequities in the delivery of basic health care services and inequities in the distribution of basic resources.

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IPSS= (Ciin-CDxin ) + (Ciap-CDxap )+ (Cips-CDxps ) Va

Ciin Ciap Cips 3

IPSS= Index of priority for health services

Ciin= Ideal coverage for immunization (100%)

CDxin= Immunization coverage for district X

Ciap= Ideal coverage for antenatal care (100%)

CDxap= Antenatal coverage for district X

Cipss=Ideal coverage for supervised deliveries (100%)

CDxps=Coverage of supervised deliveries for district X

Va= Sum of three values

NOTES: The coefficient will go from 0.01 up to 0.99

The higher the value, the higher the priority for the delivery of basic services to the population

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IR = (GPDx X 0.4 ) + (MDx X 0.3)+ (FDa X 0.3)


IR= Index of resources

GPDx= per capita expenditure district x

GPDa= District with the highest per capita expenditure

MDx= Medical staff per population for district x

MDa= District with the highest number of medical staff/pop

FDa= District with the highest number of health facilities per population (district with the lowest number of inhabitants per health facility)

FDx= health facility per population in district x

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Examples of application

  • Benchmark II: Universal access to integrated public health services

  • Definition of integrated public health: the delivery of services related to curative, preventive and health promotion, as well as services for both, transmittable and non-transmittable diseases and chronic diseases. An integrated effort should include some forms of protection against catastrophic diseases.

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Instrument #1b: Human Resources (feed analysis of non-financial barriers and inequities in the distribution of health personnel)

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Lessons learned

  • Benchmarks and their potential contribution to the analysis of inequities

    • Start by analyzing inequities in the delivery of basic health services and inequities in the distribution of basic resources

    • From here the benchmarks can help to explain the factors that may be related to the observed inequities

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Lessons learned

  • Difficulties of transferring concepts into practice

    • Identifying and assessing indicators for accountability, social participation, intersectorial work, etc.

  • Limitations related to health information systems

    • Existing system collects mainly traditional information (health service production) and has little flexibility to introduce new indicators (intersectorial work and others)

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Lessons learned

  • Skills in research team

    • Actors at sub-national levels require skills development

  • Qualitative research

    • Potential users and data collectors have little experience & skills for qualitative research

  • Planning cycle

    • The benchmarks approach seems more useful as an approach that helps the planning cycle: evaluate existing situation-design interventions-implement-evaluate. Issues related to equity and social justice within the health system can be addressed in each of the stages of the planning cycle.

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  • Team members:

    • 12 people representing the following institutions: Universidad Nacional de Loja, PAHO-Ecuador, ALDES, Universidad de Cuenca, Fundación Eugenio Espejo, Harvard School of Public Health (USA) Liverpool School of Tropical Medicine (UK)

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Work carried out during the year 2003

  • 5 workshops (two days per workshop)

  • 9 work-meetings (one day or less)

  • Outputs:

    • Adapted version to Ecuador of the generic matrix (Daniels et al 2000) with specific indicators for each benchmarks’ criteria

    • Development of data collection instruments to assess indicators

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Adaptation of generic matrix

  • Followed simmilar process to Guatemala

  • Exchange of ideas and indicators between the Guatemalan team and the Ecuadorian team.

  • Adaptation in Ecuador emphasize the assessment of recent health policies: national health system law, free MCH services law

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Field application (Jan-April 2004)

  • Two provinces: Azuay y Canar

  • 25 health facilities (11 MoH 7 social security; 7 NGO’s; 1 local government.

  • In addition, a household survey that will allow to investigate socio-economic inequalities and its relation with access to reproductive health and MCH services.

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Expected use of findings (field application)

  • Inform local government health plans

  • Inform advocacy groups in Azuay and Canar

  • Field testing of the benchmarks approach as a tool that can aid the monitoring and evaluation of health policy implementation

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Yunnan, China-rural reform

Ecuador, public health, comprehensive

Vietnam-comprehensive reform

Pakistan- community use

Chile, Nicaragua, Sri Lanka, Nigeria (ACOSHED), Bangladesh

APHA Later

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Plans for Benchmarks

  • Research Network for all sites, other efforts at monitoring reform

  • Funding for country level projects using adapted benchmarks

  • Coordination with WHO, regional organizations of WHO, World Bank, USAID

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