Health System Performance Assessment

1. Health System Performance Assessment Dr Sameen Siddiqi Capacity Development Workshop on Health System Alexandria, June 8-12

2. What is health system performance • Performance is the accomplishment of measurable outcomes relative to stated goals and objectives • Health system performance is the measurement of health outcomes in relation to the stated goals of the health system

3. Comparison of health outcomes in countries of South Asia - 2004 Source: World Health Report 2006 (data for 2004, health expenditure data for 2003); Maternal Mortality in 2005 - Estimates developed by WHO, UNICEF, UNFPA and World Bank (data on MMR)[i][i] Maternal Mortality in 2005; Estimates developed by WHO, UNICEF, UNFPA and The World Bank. World Health Organization 2007, Geneva.

4. WHO health system conceptual framework (modified) Instrumental goals Intrinsic goals

5. Health System Intrinsic Goals LEVEL DISTRIBUTION Health   Responsiveness Efficiency   Fair Financial Contribution  Quality Equity

6. Purpose of Health Systems Performance Assessment Provide decision-makers with evidence: • to inform strategies for health system development e.g. financing arrangements, provider regulation • to inform implementation of programmes by local, regional and national managers • to monitor progress towards national targets for health and health systems

7. Health system performance: Conceptual issues and Challenges • Measuring performance of health system building blocks • macro-level (national) • micro-level (sub-national, district). • Influence of non-health system determinants on health outcomes • Measuring performance • over time in country • between countries • within countries

8. Health system intrinsic goals - Health

9. Gains in life expectancy at birth - 1960-2000 in OECD Countries

10. Burden of disease by the top 20 BOD groups in Iran - 2003

14. Health system intrinsic goals – Fair Financing • Fairness of financial contribution (FFC) Index measures inequality in the distribution of household financial contributions. • Household catastrophic health expenditure is theproportion of households facing expenditure due to health payments that account for more than 40% of the annual subsistence (non-food) spending of the household.

15. Catastrophic health expenditure and impoverishment 1995–2002; Iran • Reduce expenditures on other basic needs • Push some households into poverty • May cause consumers to forgo health services and suffer illness Catastrophic health expenditures Source: Razavi 2005

16. Health system intrinsic goals - Responsiveness • Respect for persons includes: • Respect for the dignity of the person • Confidentiality • Autonomy to participate in choices about one’s own health • Client orientation includes: • Prompt attention • Presence of amenities of adequate quality • Access to social support networks • Choice of provider

17. Country Rank Index Country Rank Index Afghanistan 181 3.96 Morocco 151 4.58 Bahrain 43 5.82 Oman 83 5.27 Cyprus 11 6.88 Pakistan 120 4.95 Djibouti 170 4.28 Qatar 26 6.34 Egypt 102 5.06 Saudi Arabia 67 5.40 IR Iran 100 5.10 Somalia 191 3.69 Iraq 103 5.05 Sudan 164 4.34 Jordan 84 5.25 Syria 69 5.37 Kuwait 29 6.34 Tunisia 94 5.15 Lebanon 55 5.61 UAE 30 6.33 Libya 57 5.53 Yemen 180 3.98 Health System: Responsiveness Source: WHO Report 2000 ?

18. Responsiveness from 5 OECD Countries

19. WHO health system conceptual framework (modified) Instrumental goals Intrinsic goals

20. Health system instrumental goal: Access The Five “A”s of Access • Affordability - ability and willingness of the user to pay for services • Availability - resource provider has (staff, technology, infrastructure) • Accessibility refers to geographic accessibility • Accommodation – organization of provider’s operation (working hours, appointments) • Acceptability – conformity between user and provider (age, sex, social class, ethnicity) Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981 Feb;19(2):127-40

21. Health system instrumental goal: Coverage • Coverage is a measure of the extent to which health interventions are being delivered to the population • Immunization coverage among 1 year olds • Antenatal care coverage • Births attended by skilled birth attendants • Contraceptive prevalence rate • Tuberculosis detection rate under DOTS • Effective coverage - fraction of health gain that is actually delivered compared to what can be potentially delivered through an intervention

22. Crude and effective coverage - Hypertension treatment in Mexico 2005–08 (Black error bars show 95% CIs)

23. Quality of care is the degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge Health system instrumental goal: Quality

24. Health system instrumental goal: Efficiency • Technical or production efficiency - when no greater output at a given level of quality can be achieved with a given set of resource inputs. • Allocative efficiency - when no alternative allocation of resources can make someone better off, without at least one person being worse off.

25. Measuring Hospital Performance: WHO EURO Framework

26. Health system instrumental goal: Health Equity • Absence of systematic disparities in health between more and less advantaged social groups. • Equity in the provision of health services - accessibility to an essential health services to all regardless of social position or residence. • Equity in financing of health services - ability to pay according to need.

27. Health system instrumental goal: Equity

28. Equity in the use of physicians visits in OECD Countries

29. WHO health system conceptual framework (modified) Instrumental goals Intrinsic goals

30. Health system building blocks: Assessment tools Health system building blocks Examples of assessment tools and instruments Governance Health system governance framework Essential public health functions Financing National health accounts Health expenditure surveys Fairness of financial contribution index Workforce Health workforce surveys Health workforce observatories Infrastructure Health system analysis Technology Health technology assessment Medicine pricing surveys Information HIS assessment tools Service provision Health system analysis

31. Building blocks Instrumental goals Intrinsic goals Governance Quality Financing Responsiveness Efficiency Workforce Infrastructure Coverage Health Technology Access Fair Financing Service provision Equity Information Relationship between building blocks health system goals

32. Should countries be ranked for health system performance? • Health outcomes are influenced by • non-health system determinants • health system determinants • personal health services • non-personal or public health programs • Ranking health system performance • based on a single composite index poses a huge methodological challenge - ? • Should not detract from “measuring” health system performance of countries • No matter how crude the tools, improving health system performance is critical

33. Keep it simple!!!

34. Key strategies for improving performance – OECD countries

35. Key Messages • Health systems are complex, there is no single composite indicator that could help measure its overall performance • No country can measure all aspects, choose the most “appropriate” indicators that permit assessing health system performance: • Intrinsic and instrumental goals and building blocks • Based on priority health system needs • Available information, analytical capacity, resource availability • If health systems are to be well managed they have to be measured.