Co-coverage A useful index to monitor health systems strength?

1. Co-coverageA useful index to monitor health systems strength? Ties Boerma, WHO Health System Metrics meeting Health Metrics Network, Glion 27/9/ 2006

2. Definitions Coverage • Coverage: the percent of people receiving a specific intervention among those who need it • Effective coverage: the probability that an individual will receive health gain from an intervention if they need it

3. Basic framework INPUTS & PROCESSES Governance & leadership Finances Human resources Infrastructure Procurement Logistics & supplies Information OUTPUTS Services (availability, affordability, quality) UTILIZATION Coverage Behavioural change OUTCOME Improved health Reduced mortality OTHER DETERMINANTS OF HEALTH (ECONOMIC, SOCIAL, POLITICAL)

4. Individual level co-coverage • Children 1-4 years, preventive interventions, single survey • Immunization overage (BCG, DPT3, measles) • TT to mother (>=2 doses) • Skilled birth attendance • Vitamin A supplementation in last 6 months • ANC (>= 4 visits) • Access to safe water • 8 DHS surveys, primary focus on assessing inequity in coverage by wealth quintile

5. Co-coverage of 8 MCH interventions(mean, concentration index >6 interventions)

6. Trend in 5+ childhood preventive interventions coverage, DHS surveys, selected countries

7. Individual levelChild co-coverage Weaknesses • Only preventive interventions • Limited set of coverage variables • Children only – adults ? (BP, mammography, PSA etc.) • Observations not entirely independent • Dependence on household surveys means low frequency Strengths • Multiple interventions gives more complete picture of coverage • Data from one source – national pop based survey • Ability to disaggregate

8. Co-coverage based on aggregate scores • Based on internationally comparable health statistics • Should be sensitive to the strength of health systems • Mexico – 13 interventions with consistent estimates, focus on effective coverage (health gain); effect weights limited

9. Potential statistics for co-coverage score

10. Co-coverage scoreDashboard potential?

11. Co-coverage score by total health expenditure per capita (int. dollars)

12. Co-coverage score by health worker density

13. Co-coverage by life expectancy

14. Data sources • Coverage surveys: MICS, comprehensive surveys, determining need to move to effective coverage • DHS promoting coverage surveys • Local surveys using PDA GPS devices • Use of facility data to estimate trends • Sentinel facilities • Calibrated by regular coverage surveys

15. Skilled birth attendant coverage, Namibia Number of deliveries in government and mission hospitals, service reports, Namibia 1999-2004 Reporting rates by facility => adjustment Namibia MoH 77,000 and increasing UN 62,000 and decreasing • Response quality assessment • Consistency • Field evaluation • Sentinel sites Denominator for coverage => Census projections Percent of deliveries in health facilities in 3 years preceding the survey, DHS 1992, and 2000, Namibia Reconciliation data sources

16. Reconciling data from different sources: medically supervised delivery care, Ghana Overestimation 2000-03 8%

17. Discussion • Potentially simple measure to monitor that could provide general information about strength health system • Limitations have to be taken into account • Further work • Best set of coverage indicators • Weighting