Dr. Shahram Yazdani Intermediary Measures in Health System Performance Assessment.

Dr. Shahram Yazdani

Intermediary Measures in Health System Performance Assessment

Dr. S

hahra

m

Yazd

ani

Intermediary Measures

Experience shows that when a health sector reformer seeks to understand the causes of unsatisfactory outcomes, certain characteristics of the system often play an important role.

These characteristics are not, in themselves, either the root causes of performance difficulties or the manifestations of those difficulties at the level of ultimate outcomes.

These factors are named as intermediary performance characteristics, because they are critical links in the chains that connect root causes to ultimate performance goals.

Dr. S

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m

Yazd

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Intermediary Measures

Intermediate performance characteristics that should be singled out for special attention:

1. Efficiency

2. Coverage

3. Quality

Dr. Shahram Yazdani

Efficiency

Dr. S

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m

Yazd

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Efficiency

Efficiency measures whether healthcare resources are being used to get the best value for money.

Dr. S

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Yazd

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Efficiency

Efficiency is concerned with the relation between resource inputs (costs, in the form of labor, capital,or equipment) and either intermediate outputs (numbers treated, waiting time, etc) or final health outcomes (lives saved, life years gained, quality adjusted life years (QALYs)).

Dr. Shahram Yazdani

Technical efficiency “doing things right”

D1 N1 DALY1 I11 C11 E11 I12 C12 E12 I13 C13 E13 I14 C14 E14

E1i Is The Percent Reduction In DALY Lost

*

DALY Saved For I12 (Technically Efficient Intervention)= DALY1 × E12

Total Cost = N1 × C12

Max E1i

C1iTechnical Efficiency =

*

Max E1iMost Effective Intervention =

Usually we have not enough resources for using the most effective interventions

DALY Saved For I11 (Most Effective Intervention)= DALY1 × E11

Total Cost = N1 × C11

DALY1 × E11 > DALY1 × E12

Shift from Most Effective to Technically Efficient Is a Kind of Rationing

Dr. S

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Yazd

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Technical efficiency

Technical efficiency refers to the physical relation between resources (capital and labor) and health outcome.

A technically efficient position is achieved when the maximum possible improvement in outcomes obtained from a set of resource inputs.

An intervention is technically inefficient if the same (or greater) outcome could be produced with less of one type of input.

Dr. S

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Yazd

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Technical efficiency

Consider treatment of osteoporosis using alendronate. A recent randomized trial showed that a 10 mg daily dose was as effective as a 20 mg dose. The lower dose is technically more efficient.

Dr. S

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Yazd

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Input quantities vs. input cost

Almost all main definitions take technical efficiency to refer only to input quantities, and not input costs in monetary terms

Dr. S

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Economic Efficiency

The cost of any production process is, of course, influenced not only by the quantities of inputs used, but also by the cost of these inputs.

A production unit which is economically efficient will produce a given output for the minimum possible total input cost, or maximize output for a fixed value input budget.

Thus, an economically efficient firm is, by definition, a cost-minimiser.

Dr. S

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Yazd

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Economic Efficiency This formulation of economic efficiency is

particularly important in considering health care interventions.

Clinicians (quite reasonably) tend frequently to focus on best practice in terms of inputs – but differences in relative input prices may mean that a technically efficient “best practice” is economically efficient in one country but not in another.

This possibility is clearly a key practical constraint upon attempts to produce truly international “evidence based medicine” and to develop easily generalizable cost-effectiveness results.

Most Effective InterventionMost Efficient Intervention

D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

**

**

**

**

***


D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

**

**

**

**

***

Moving from less effective interventions To


D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

**

**

**

**

***

Moving from less effective interventions ToMost effective interventions

Perform

ance

Cost

BPerform

ance

Cost

A

Moving from less effective interventions ToMost effective interventions


D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

**

**

**

**

***

But we have not enough resources to ensure delivery of most effective interventions

Moving from most effective interventionToMost efficient interventions


D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

**

**

**

**

***


BPerform

ance

Cost

A


C

Effectiveness to Technical Efficiency Rationing

Perform

ance

Cost

A

Moving from a more costly, less effective intervention to most efficient intervention usually is the case

C

Dr. Shahram Yazdani

Allocative efficiency “doing the right things”


D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

**

**

**

**

***

DALY1×E12

DALY2×E23

DALY3×E33

DALY4×E41

DALY5×E53

DALY6×E64

DALY7×E72

DALY8×E81

DALY9×E92

But we have not even enough resources to ensure delivery of most efficient interventionsDALY gain if we adhere to technical efficiency in all problems

Moving from Technical EfficiencyToAllocative Efficiency


D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

**

**

**

**

***

DALY1×E12

DALY2×E23

DALY3×E33

DALY4×E41

DALY5×E53

DALY6×E64

DALY7×E72

DALY8×E81

DALY9×E92

×

××

×

Moving from Technical efficiencyToAllocative Efficiency

Selecting the right set of technically efficient interventions

Technical Efficiency to Allocative Efficiency Rationing

Dr. S

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Yazd

ani

Allocative efficiency

To inform resource allocation decisions in broader context a global measure of efficiency is required.

The concept of allocative efficiency takes account not only of the productive efficiency with which healthcare resources are used to produce health outcomes but also the efficiency with which these outcomes are distributed among the community.

Such a societal perspective is rooted in welfare economics and has implications for the definition of opportunity costs.

Dr. S

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Allocative Efficiency

Thus allocative efficiency is conventionally defined as being achieved in a situation in which it is impossible to improve the welfare of anyone without reducing the welfare of someone else through a change in the output combination (the achievement of a Pareto-optimal state).

Explicitly, technical and economic efficiency are necessary but not sufficient conditions for allocative efficiency to be achieved.

Dr. S

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Allocative Efficiency -Definition

“It [the firm]…produces the correct mix of outputs, given output prices, uses the correct mix of inputs, given input prices, and adopts the correct scale given input and output prices: this is what allocative efficiency requires.”

Knox Lovell and Schmidt (1988)

Dr. Shahram Yazdani

Technological efficiency “moving to new right things”


D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

**

**

**

**

***

Technology Push to more effective but not necessarily more efficient interventions


D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

**

**

**

**

**

*


I35 C35 E35

I55 C55 E55

I75 C75 E75

I85 C85 E85

I95 C95 E95

Ne

w

Te

chn

olo

gy


D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

*

**

*

*

*


I35 C35 E35

I55 C55 E55

I75 C75 E75

I85 C85 E85

*

*

**

I95 C95 E95 *

Ne

w

Te

chn

olo

gy

Perform

ance

Cost

A

C

Effect of Technology Development

Flat of Curve Development


D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

*

**

*

*

*


I35 C35 E35

I55 C55 E55

I75 C75 E75

I85 C85 E85

*

*

**

I95 C95 E95 *

Perform

ance

Cost

A

B


Steep of Curve Development


D1 N1 DALY1

D2 N2 DALY2

D3 N3 DALY3

D4 N4 DALY4

D5 N5 DALY5

D6 N6 DALY6

D7 N7 DALY7

D8 N8 DALY8

D9 N9 DALY9

I11 C11 E11

I21 C21 E21

I31 C31 E31

I41 C41 E41

I51 C51 E51

I61 C61 E61

I71 C71 E71

I81 C81 E81

I91 C91 E91

I12 C12 E12

I22 C22 E22

I32 C32 E32

I42 C42 E42

I52 C52 E52

I62 C62 E62

I72 C72 E72

I82 C82 E82

I92 C92 E92

I13 C13 E13

I23 C23 E23

I33 C33 E33

I43 C43 E43

I53 C53 E53

I63 C63 E63

I73 C73 E73

I83 C83 E83

I93 C93 E93

I14 C14 E14

I24 C24 E24

I34 C34 E34

I44 C44 E44

I54 C54 E54

I64 C64 E64

I74 C74 E74

I84 C84 E84

I94 C94 E94

***

**

**

*

**

*

*

*


I35 C35 E35

I55 C55 E55

I75 C75 E75

I85 C85 E85

*

*

**

I95 C95 E95 *

Perform

ance

Cost

AC


Pseudo-development

Dr. S

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Technological Efficiency

Technological change occurs through the development of new processes which can produce more output for the same or less input than older processes;

The introduction of such a new process can be thought of as rendering all previous processes technically inefficient.

Under this view, “technology’ consists of the series of all known techniques for producing a particular output – although the invention of a new technique does not necessarily mean it will be available to all producers or all countries (Meier, 1995).

Dr. S

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Technological Efficiency

Clearly, though, there is a difference between inefficiency due to operating off the isoquant for a given technology, as opposed to inefficiency due to failing to move to a different isoquant made possible by a new technology.

Dr. Shahram Yazdani

Efficiency Summary

1

2

3

4

5

6

7

8

9

Perform

ance

Cost

Cost performance dilemmas

1- Accept somewhat reduced performance in order to significantly reduce cost2- Save as much as possible without reducing outcomes3- Improved efficiency to both lower cost and raise performance4- Maximize performance for the current budget5- Improve performance to such an extent that more money is required6- Increase in cost without increase in performance7- Increase in cost and decrease in performance8- Increase in performance on the flat of the curve,9- Increase in performance on the steep of the curve,

1

2

3

4

5

6

7

8

9

Perform

ance

Cost

Cost performance dilemmas

Countries like Armenia or Tajikistan, in the aftermath of war or civil disorder, may find it necessary to focus on cost reduction, as shown by 1 or 2 Countries like Brazil or Russia, which are growing, may be primarily concerned with improving performance—even if cost rises somewhat, as shown by 4 or 5

A

B

C

Ministries of finance often argue that the nation is a point A and a change like 3-more performance and lower cost-is required The ministry of health in contrast tends to argue that the system is at C and that move 9-more spending for more health-is the only appropriate response.

Dr. Shahram Yazdani

Coverage

Dr. S

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Effective coverage

Effective coverage is defined as the proportion of the population in need of an intervention who have received an effective intervention.

The numerator of the coverage ratio should indicate the number of population units (individuals, houses, villages) receiving effective interventions,

The denominator should refer to the population that would need the type of services indicated in the numerator.

Dr. S

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Effective coverage

There are three main conceptual elements of effective coverage: access, utilization and effectiveness.

Access was defined in terms of availability, accessibility, affordability and acceptability.

Utilization was the combination of access and personal health behavior.

Effectiveness was considered a function of several variables, including efficacy, inputs (amount and quality of resources), quality assurance mechanisms (process of service delivery, provider performance), patient compliance and health behavior, and external factors (environmental, biological, social, etc.).

EffectiveCoverageUtilization

Effectiveness

Access personal

health behavior

Affordability

Availability

Acceptability

Accessibility

Efficacyinputs (amount and quality of

resources)

quality assurance mechanisms (process

of service delivery, provider performance),

patient compliance and health behavior, external factors

(environmental, biological, social, etc.).

Dr. S

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Effective coverage

Effective coverage is different from the effectiveness of the intervention itself.

For example, the effectiveness of DTP properly administered, is known to be high.

However, unless the quality of the vaccine and the administration can be ensured, effective coverage with DTP even among those receiving the vaccine, might be low.

Dr. S

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Effective coverage

Some experts suggested that the term coverage with effective interventions be used instead of effective coverage.

They were of the opinion that effective coverage would best refer to the proportion of people for whom the health intervention had actually produced a desirable health outcome.

Dr. S

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Coverage Dimensions

There are six different aspects of coverage, which could be analyzed in trying to determine where problems lay in achieving effective coverage. Availability coverage Accessibility coverage Acceptability coverage Affordability Coverage Contact coverage Effective coverage

Dr. S

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Availability Coverage

The proportion of people for whom sufficient resources and technologies have been made available.

The ratio of resources to the total population in need.

The proportion of facilities, which offer specific resources, drugs, technologies, etc.

Dr. S

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Accessibility Coverage

The proportion of people for whom health services are accessible in terms of their distance or travel time.

Dr. S

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Acceptability Coverage

The proportion of people for whom interventions are acceptable (cultural acceptability, beliefs, religion, gender, etc.).

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Affordability Coverage

The proportion of people for whom health services are affordable.

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Contact Coverage

The proportion of the population that has contacted a health service provider.

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Effective Coverage

The proportion of the people who have received effective interventions.

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Identification of Interventions for the Measurement of Effective Coverage Ability to produce a significant health gain in a relatively

short time. The size of a health problem at the global and country

levels. Evidence on the effectiveness of an intervention and its

inherent credibility. Correspondence to the national health policies, priorities

and objective needs. Balance between the different modalities of health care,

from preventive to curative, and between the various types of illnesses: communicable, non-communicable, life cycle related health conditions, etc.

Cost-benefit ratio of obtaining information at the country level.

Ability to link the global processes with the country priorities for the benefit of the latter.

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Gaps in Effective Coverage

In order to make the measurement of effective coverage more operational, a framework in which the gap between actual and maximum effective coverage is decomposed into seven components: Resource availability gap Physical accessibility gap Affordability gap Cultural acceptability gap Provider-related quality gap Adherence gap Strategic choice gap

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Quality

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Definition

“Quality” can be used to mean simply the quantity of care provided to a patient, as in: “My aunt got the highest quality care. They

did everything for her.” Americans who praise their system for its

high “quality” often are using the term in this way.

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Definition

The second basic meaning of “quality,” which health professionals typically use, refers to clinical quality.

This involves both the skill of caregivers (e.g., the surgeon’s technique) and the correctness of diagnostic and treatment decisions.

It also depends on whether the right inputs (e.g., drugs, equipment) are available to carry out appropriate care.

Clinical quality also depends on the system of production that combines these inputs into actual delivered services

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Definition

The third broad usage, which is most often invoked by patients who find it difficult to judge clinical quality, involves service quality.

The subcategories here are themselves multi-dimensional.

Hotel services include food, cleanliness, and the nature of hospital and waiting rooms.

Convenience includes travel time, waiting time, opening hours, and the time necessary to get an appointment.

The interpersonal dimension involves whether providers are polite and emotionally supportive, and whether patients are given appropriate information and treated with respect.

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Meanings for the term “quality” in health care

Clinical quality Service quality

Human Inputs: skill, decision making

Hotel Services: food, cleanliness

Non Human Inputs Convenience: Travel and waiting times

Production System Interpersonal Relations: Care, politeness, respect

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Measuring Quality

Comparing clinical care (as recorded in patient records, for example) with expert opinion is one way to determine whether appropriate treatment has been given, as long as those records are themselves accurate.

However, it is expensive and time-consuming to make such an assessment.

Quality can also be measured indirectly by outcome data like infection rates, operative mortality, and so on.

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Measuring Quality

The difficulty of collecting and interpreting sophisticated quality data helps explain why many countries rely heavily on regulating inputs (e.g., educational requirements) rather than monitoring and evaluating processes or outcomes in the quality arena

Indeed, looking at inputs (does the health center have needed drugs and equipment, is a doctor available) is often the only—albeit highly imperfect—way for patients to assess clinical quality.

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Distribution of Quality

Not just the average, but also the distribution of quality (that is, who is subject to poor quality) is often important to the connection between quality and system performance

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The first question a reformer has to ask about health care quality involves a special kind of technical efficiency.

Is each service being produced in a way that results in the highest possible quality given the costs being incurred?

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ani For a specified level of spending per unit of service, any medical care system can

only produce a limited level of clinical or service quality.

Quality Possibility Frontier

For managers to know whether we are on or at least near the frontier will require some form of benchmarking

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There is a second quality question. Even if a service is operating on the quality possibility frontier, are the producers offering an appropriate mix of qualities?

If we have a construction budget for a new clinic, should we spend more on a more comfortable waiting room and less on a new x-ray machine, or vice versa

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There is yet a third quality issue. Series of quality possibility frontiers is available for any given service, each based on a different budget level.

The third task then is evaluating the level of spending for each service, which in turn determines just what quality levels can be produced for that service.

This is the quantity aspect of quality that we identified initially. The issue is, What level of resources should we devote to each service?

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Objective utilitarians approach to quality

How would different reformers, with different philosophical views, judge the performance of the healthcare system with regard to quality?

Objective utilitarians, interested in health maximization, would want to produce the maximum clinical quality for any given budget

They would then evaluate budget levels based on marginal cost effectiveness analysis, to see if money was being spent on different services in a way designed to produce the biggest health status gain.

Notice, however, that the way we have drawn the frontiers implies that objective utilitarians would make a mistake in assuming that they can always increase clinical quality by decreasing service quality. Beyond some point, lowering service levels discourages utilization, lowers patient compliance, and impedes communication, all of which can lead to poorer clinical results.

In fact, some real systems (especially public clinics in poor countries) may well be in this paradoxical situation.

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Subjective utilitarians approach to quality

Subjective utilitarians, interested in maximizing customer satisfaction, face a slightly different evaluation process.

Since patients care about many different aspects of both clinical and service quality, subjective utilitarians have to decide whether the quality mix and spending level for each service represents an optimal response to the varied individual preferences of its customers.

The obvious difficulty of such a task helps explain why so many subjective utilitarians favor using markets in health care.

Markets allow everyone to choose (and pay for) the set of services, and the mix and level of qualities, that they prefer. Of course this assumes that customers (i.e., patients) can judge quality levels, which is doubtful when it comes to clinical quality

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Benchmarking

Ethical benchmarking comparing performance to general ethical norms

Internal benchmarking comparing performance across groups or regions within the country

Historical benchmarking comparing performance to a nation’s own prior performance

External benchmarking comparing performance with that of other, similarly situated countries

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Thank You !

Any Question ?

Dr. Shahram Yazdani Intermediary Measures in Health System Performance Assessment.

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