Measuring to Manage Progress toward Universal Health Coverage
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Transcript of Measuring to Manage Progress toward Universal Health Coverage
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Measuring to Manage Progress toward Universal Health CoverageBen BellowsOn behalf of the Social Franchise Metrics Working GroupNHIS 10th Anniversary International Conference on UHCAccra
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UHC is multidimensional & aspirationalAccess: Expand coverage to wider populationScope: Improve quality & quantity of health services offeredFinancial protection: Improve size of subsidies or reduce informal charges
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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.
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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
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Selected constructs and metrics for UHC measurementQuality of care:• Donabedian framework (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
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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
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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)
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PPI tools
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DHS questions
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Quintile India Madag Benin DRC Mali
n=797 n=853 n=535 n=242 n=293
1 (Poorest) 27.9 2.1 3.4 0 0
2 (Poorer) 22.5 9.3 2.4 0 0
3 (Middle) 21.7 25.4 4.3 0 0.3
4 (Richer) 15.3 38.6 13.1 9.1 13.9
5 (Richest) 12.7 24.6 76.8 90.9 85.7
Results & indicator attributes
Wealth IndexRelative measureUses DHS data to compare client sample
to national wealth quintilesLow-cost because DHS data is publicly
available
PPIAbsolute measureAsset list gives likelihood that a client is
under $1.25/day poverty threshold Expensive: unique asset weights developed
for each country
Only 6% of Benin franchise clients are from the bottom 40% of the population
Threshold Clients Benin Pakistan Philippines Vietnam
$1.25/day
Franchise 19% 17% 17% 8%
National 47% 21% 18% 17%
$2.50/day
Franchise 61% 72% 51% 51%
National 75% 60% 42% 43%
19% of Benin franchise clients living under the $1.25/day threshold vs. 47% of the national population
BOTH METRICS GIVE SIMILAR RESULTS
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Selection criteria
Criteria PPI Wealth IndexEasy to Collect and Interpret
Easy to collect Easy to calculate Easy to interpret poverty threshold
Easy to collect Difficult to calculate Quintiles widely used/understood
Low Cost $20,000-$25,000 per country Requires some upkeep costs
Inexpensive Based on publicly-available DHS
Comparable to National Context
Percent of clients under poverty line easily comparable to national poverty rate
Difficult/impossible subgroup analysis e.g.: just urban, or just FP clients
Wealth quintiles accurate and validated comparison to national distribution
Easy subgroup analysis
Comparable Across Countries
Percentage of clients under $1.25/day standard across countries
Can discuss percentage of clients that fall within bottom 40%, but measure is relative to a country
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Using Wealth Index routinely
• Randomly select NHIS facilities or enrollment centers• Conduct exit 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-annual basis
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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.
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Respondents who had ever used the HealthyBaby voucher in Uganda (2010-2011)
Poorest quintile
Poorer quintile
Middle quintile
Richer quintile
Richest quintile
0%5%
10%15%20%25%30%35%
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Does NHIS enrollment vary by wealth quintile?
Poorest Less poor Middle Less rich Richest0%
10%
20%
30%
40%
50%Women (DHS 2008)All (SHINE, 2009)
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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?
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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