L2 uhc-indicators-measurements-jk
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Transcript of L2 uhc-indicators-measurements-jk
Under JPG Teaching Fellowship
Permission from JPGSPH
CoE-UHC
Universal Health Coverage
Indicators and Measurements
Jahangir A. M. Khan, PhD
Head, Health Economics and Financing Research Group
Centre for Equity and Health Systems, icddr,b
Associate Professor, JPGSPH
Defining Universal Health Coverage
WHO, 2005 says:
Universal health coverage means that everyone in the population has access to appropriate promotive, preventive, curative and rehabilitative health care when they need it and at an affordable price.
Three dimensions of UHC
Population coverage
Service coverage
Financial risk protection
Three dimensions of UHC
All people in the country have access to adequate healthcare
Population segments
Sex
Age
Population coverage
Male
Female
Transsexual
Children (0-17 years)
Adults (18-64 years)
Elderly (65 years and above)
Pre reproductive age
Reproductive age
Post reproductive age
Geographic location
Urban: Slum
Non-slum
Rural: Reachable
Hard-to-reach
Low
Lower middle
Middle
Upper-middle
High
Income groups
Socioeconomic groups
Asset index based quintile
Poorest
2nd quintile
3rd quintile
4th quintile
Richest
Economic & labor market segments
People below poverty line
People in informal sector
People in formal sector
Country SHI
status
Pop
(in thousand)
Age dependency
ratio
Urban pop
Bangladesh N.A. 160,000 0.49 0.06 26%
Kenya Designing 38,765 0.78 0.05 21%
Ghana Initiation 23,351 0.67 0.06 48%
Philippines Expansion 90,348 0.54 0.07 63%
Colombia Matured 45,012 0.45 0.08 74%
Thailand Achieved 67,386 0.30 0.11 32%
Service coverage
WHO says:
Promotive, preventive, curative and rehabilitative
care
How health system is structured:
Public Health Service Arrangement in Bangladesh
Types of care Care providing agents
Primary care: Community clinics
Union Health Centers
Secondary care: Sub-district (Upazila) Health Complex
District hospitals
Tertiary care: Regional hospitals
Providers Services Promotive Preventive Curative Rehabilitative
Public
?
Community clinic, Union health
centers, vertical programs (EPI,
MNCH, TB)
Sub-district, District, Regional hospitals
?
Private for profit Urban areas (high concentration in
metropolitan cities and district towns & some
in sub-districts)
Some urban areas (mostly metropolitan
cities)
Private not for profit Yes Yes To a small scale To a small scale
Informal providers To some extent To some extent
Supply-side: Service and provider map
Assuring supply does not necessarily mean need-based utilization
Under-utilization is observed
Many sub-district hospitals are partially empty
Over-utilization is observed too
Visiting specialists when not required, Drugs, diagnostic tests
Do you agree?
Equipping the supply of services is
a prerequisite for coverage, not the
final goal.
Now, where should we try to observe the success in
achieving coverage?
Jointly,
Population in total and across population segments
Service utilization
Indicators of “population and service” coverage
Health system
agents
Indicators: Service/care available Distributional dimensions
Levels
Su
pp
ly-s
ide
Number of doctors per 1,000 people
Urb
an
: S
lum
s a
nd
no
n-s
lum
s A
ND
ru
ral
rea
cha
ble
an
d
ha
rd-t
o-r
each
are
as
Acr
oss
so
cio
eco
no
mic
gro
ups
Number of nurses per 1,000 people
Number of midwives per 1,000 people
Number of dentists per 1,000 people
Number of physiotherapists per 1,000 people
Number of community health workers per 1,000 people
Number of public health workers per 1,000 people
Number of nutritionists per 1,000 people
Number of hospital beds per 1,000 people for secondary care
Number of hospital beds per 1,000 people for tertiary care
EPI coverage
Dem
an
d-s
ide
Number of visits per 1,000 pop in community clinics
Number of visits per 1,000 pop in union health centers
Number of visits per 1,000 pop in sub-district health complex
Number of visits per 1,000 pop in district hospitals
Number of visits per 1,000 pop in regional/referral hospitals
Bed occupency ratio in district hospitals
Bed occupency ratio in regional/referrral hospitals
Number of children vaccinated through EPI system
Financial risk protection
No one should die and suffer because they cannot afford
health care, and no one should be made poorer because they
get sick.
Affordability for purchasing or availing healthcare
varies across income or socioeconomic groups.
Distribution of out-of-pocket payments across income
groups shows the ability.
Health Financing and Financial Protection
Three principal objectives of Indian UHC report (2012):
Objective 1: ensure adequacy of financial resources for the
provision of essential health care to all
Objective 2: provide financial protection and health security against
impoverishment for the entire population of the country
Objective 3: put in place financing mechanisms which are
consistent in the long-run with both the improved well-being of the
population as well as containment of health care cost inflation
Financing mechanisms
Taxation Private health insurance Out of pocket payments Medical savings accounts Social health insurance Community-based health insurance Loan, grants and donations
Risk/fund pooling
Pre-payment system verses post-payment (out-of-pocket)
Which mechanisms protect your financial risk
Health expenditure by Financing Agents and Mechanisms
In Bangladesh, 2007
Agents Mechanisms Expenditure
(in MBDT)
Percentage of
THE
Public sector Tax, donation 41,318 26%
Households Out-of-pocket 103,459 64%
Private Firms Pay-roll tax type 1,325 1%
Private Insurance Health insurance 314 0%
NGO Donation 2,092 1%
Rest of the World Donation, grant 12,391 8%
Total 160,899 100%
Source: National Health Accounts, 2007
Health expenditure per capita = 16 US$
Health expenditure as a percentage of GDP = 3.4%
Indicators: Financial risk protection
Levels (National) Distributional
dimensions
Health expenditure per capita
Urb
an:
Slu
ms
and
non-s
lum
s
AN
D r
ura
l re
ach
ab
le a
nd
hard
-to-r
each
are
as
Acr
oss
so
cio
econo
mic
gro
up
s
Health expenditure as % of GDP
Share of health spending in total government expenditure
Public spending in health (per capita & as % of THE)
Private spending in health (per capita & as % of THE)
OOPP for health (per capita & as % of THE)
OOPP in health total household consumption expenditure
Social HI contribution (per capita & as % of THE)
CBHI contribution (per capita & as % of THE)
Private HI contribution (per capita & as % of THE)
Indicators showing distributional aspects
Descriptive statistics
How indicators showing “level” are distributed across
groups of population
Composite measurements
Concentration index
Gini-coefficient
Kakwani index
Dominance test
Po
pu
lati
on
seg
men
t
Service
Public
primary
Public
district
hospital
Public
Regional
& referral
hospitals
Total
public
NGO
health
centre
NGO
hospitals
Total
private
not for
profit
Private
for profit
facilities
Pharmacy Total
private for
profit
All
types
Poorest X X X X X X X X X X X
2nd
X X X X X X X X X X X
3rd
X X X X X X X X X X X
4th
X X X X X X X X X X X
Richest X X X X X X X X X X X
CI
KI
Benefit Incidence Analysis
(BIA)
BIA aims at presenting how “benefits” either in terms of quality of good and services or its
monetary values are distributed across groups of people (like, socioeconomic groups).
Po
pu
lati
on
seg
men
t
Types of funding mechanism
Direct tax Indirect tax User fee Social
security
contri
CBHI
contri
Pvt
Ins contri
OOPP Total
payment
Poorest X X X X X X X X
2nd
X X X X X X X X
3rd
X X X X X X X X
4th
X X X X X X X X
Richest X X X X X X X X
CI
KI
Financing Incidence Analysis
(FIA)
FIA aims at presenting how “payments to a system” (like, healthcare) are distributed across
groups of people (like, socioeconomic groups).
Concentration index (CI)
What does CI mean: Concentration curve plots cumulative proportion population (ranked from the poorest to the richest socioeconomic condition) in x-axel against cumulatove poportion health in y-axel.
Cumulative proportion population (ranked from poorest to richest)
Cu
mu
lati
ve p
rop
ort
ion
OO
PP
20%
40%
60%
80%
100%
20% 40% 60% 80% 100%
O
B´
B
C
Construction of concentration index
CI = 2 * (Area under
diagonal – area under
lorenz curve)
CI ranges between
-1 and +1
Why CI is a good measurement, especially for addressing UHC:
1. It reflects the experiences of the entire population.
2. It reflects the socioeconomic dimension of benefits/payments etc.
3. It is sensitive to changes in the distribution of the population across the
socioeconomic groups.
Construction of Gini-coeffcient
G = 2 * (Area under
diagonal – area under
lorenz curve)
G ranges between
0 and +1
Cumulative proportion population (ranked from lowest to highest income)
Cu
mu
lati
ve p
rop
ort
ion
in
com
e
20%
40%
60%
80%
100%
20% 40% 60% 80% 100%
O
B´
B
C
Kakwani Index (KI)
KI measures “Progressivity of health care payments”
KI = CI of payments – G of household consumption expenditure
KI value ranges between -2 to +1.
Progressivity of health care financing and
incidence of service benefits in Ghana
James Akazili, Bertha Garshong, Moses Aikins, John Gyapong, Di McIntyre4
Health Policy and Planning 2012;27:i13–i22
Estimating socioeconomic status
Household consumption expenditure (per equivalent adult)
Quintile distribution of households
Assessing proportionality of health care financing
Progressive
If payments are made more than proportional increase in income
Proportional
If payments are made as same proportion as income increase
Regressive
If payments are made in a lower proportion than increase in income
Estimating benefits of health service used
Benefit incidence is calculated by multiplying the utilization rate of each
type of service for each socio-economic group by the unit cost of that
service.
Assessing need for healthcare
Self-assessed health: ‘How would you rate your health in general?’
Very good’
Good’
Average’
Poor’.
Need was then measured as the percentage of individuals who rated
themselves as having poor health by socio-economic group.
Data used
Ghana Living Standard Survey (GLSS)
Distribution of healthcare financing incidence
Financing Incidence Analysis
Distribution of total benefit from health
service use by socioeconomic status
Benefit Incidence Analysis
Benefits and need of health services
Can we do BIA and FIA in Bangladesh?
Existing data
Household Income and Expenditure Survey, 2010
SUMMARY
Population classification
Benefit incidence
Financing incidence
Empirical study