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Measuring to Manage Progress toward Universal Health Coverage

Measuring to Manage Progress toward Universal Health Coverage. Ben Bellows On behalf of the Social Franchise Metrics Working Group NHIS 10 th Anniversary International Conference on UHC Accra. UHC is multidimensional & aspirational. Access : Expand coverage to wider population

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Measuring to Manage Progress toward Universal Health Coverage

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  1. Measuring to Manage Progress toward Universal Health Coverage Ben Bellows On behalf of the Social Franchise Metrics Working Group NHIS 10th Anniversary International Conference on UHC Accra

  2. UHC is multidimensional & aspirational Access: Expand coverage to wider population Scope: Improve quality & quantity of health services offered Financial protection: Improve size of subsidies or reduce informal charges

  3. Access is far from universal in 54 LMIC • Of 12 MNH interventions in a review of public data across 54 countries, family planning was the third most inequitable *Barros, A. J. D., Ronsmans, C., et al. (2012). “Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries”. Lancet, 379(9822), 1225-33.

  4. Limited financial protection is common in 51 LMIC* • 13–32% of household expenditures over 4 weeks went to healthcare • 25% poor households incurred potentially catastrophic healthcare expenses • >40% of households used savings, borrowed money, or sold assets to pay for care • 41-56% of households spent 100% of health care expenditures on medicines *Wagner, Graves, Reiss, LeCates, Zhang, Ross-Degnan. 2011. “Access to care and medicines, burden of health care expenditures, and risk protection: Results from the World Health Survey” Health Policy. 100(2-3):151-158

  5. Selected constructs and metrics for UHC measurement Quality of care: • Donabedianframework (structure, process, outcomes) • Investment in facility infrastructure Financial protection: • Out-of-pocket spending on health paid for by the patient at the point of service • Proportion of household consumption that is spent on healthcare Equitable access: • Geographic proximity • Above or below a poverty line • Member of a wealth quintile

  6. Preferred characteristics in a UHC equity measure • Program Managers • Quick, inexpensive to collect • Easy to interpret by managers and field staff • Agency Headquarters • Standardized & comparable nationally • Easy to explain to policy makers • Other Stakeholders • Comparable internationally • Clients • Transparent, trustworthy, quick application process • Time-delimited membership • Recognition of solidarity • Recourse for appeal

  7. Pilot study: Find a good routine, monitoring equity indicator • MPI dismissed: not feasible to collect • PPI and Wealth Index piloted in 5 countries in 2012 as part of franchise client exit interviews • Results compared against selection criteria Progress out of Poverty Index (PPI) Wealth Index (WI) Multi-dimensional Poverty Index (MPI)

  8. PPI tools

  9. DHS questions

  10. Results & indicator attributes Wealth Index PPI Absolute measure Asset list gives likelihood that a client is under $1.25/day poverty threshold Expensive: unique asset weights developed for each country Relative measure Uses DHS data to compare client sample to national wealth quintiles Low-cost because DHS data is publicly available Only 6% of Benin franchise clients are from the bottom 40% of the population Both metrics give similar results 19% of Benin franchise clients living under the $1.25/day threshold vs. 47% of the national population

  11. Selection criteria

  12. Using Wealth Index routinely • Randomly select NHIS facilities or enrollment centers • Conductexit surveys among clients • 20 questions about household characteristics • Adds approximately 10 minutes to each interview • Centralized data analysis in M&E unit – takes about 8 hours • Build capacity through a tool kit and standard syntax files • Conduct surveys on quarterly or semi-annualbasis

  13. Uganda & Kenya: Equity targeting for program enrollment • Uganda & Kenya voucher programs • Every client identified in the community using a short targeting tool • Voucher expires after a year and can only be used for one service package.

  14. Respondents who had ever used the HealthyBaby voucher in Uganda (2010-2011)

  15. Does NHIS enrollment vary by wealth quintile?

  16. Conclusions: Active equity targeting is key component of UHC • Tools exist that can cost-effectively identify the poor for enrollment who, in the absence of the active identification, would not have become NHI members • Monitor samples of clients for reporting against performance targets • Use for beneficiary identification and enrollment • Consider: Are other exemptions as effective to achieve the same objective?

  17. Thank you Social Franchising Metrics Working Group • Bill & Melinda Gates Foundation • DKT • International Planned Parenthood Federation • Johns Hopkins • Marie Stopes International • Population Services International • Rockefeller Foundation • Population Council • University of California San Francisco • USAID • World Health Partners

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