V R M U RA L E E D H A RA N , I I T M A D RA S3 O C T O B E R 2 0 1 4

MEASURING /MONITORING PROGRESS TOWARDS UHC

A KEY QUESTION IN PUBLIC POLICY (DEVELOPMENT PROGRAMME INTERVENTION)

• How well are the benefits of public spending (on health care) distributed across socio-economic groups?

• Are the poor getting their “fair share” of the benefits of public spending (on health care)?

UTILIZATION: TN (GIRIJA ET AL. 2011)

UTILIZATION: ORISSA (GIRJA ET AL 2011)

WHAT TO MEASURE?

How do we assess the progress of NRHM?

What are its “declared objectives”? :

Provide “accessible, affordable, and quality of care to rural population”.

ACCESS? UTILIZATION?

• Definitions are important (What do we want to measure, observe?)

• What can be Measured? (proxies)• Methods of measurement (Quantitative/Qualitative,

surveys, interviews, observational. etc.)• Frequency and duration (of observations) • Who is observing? • Analysis and presentation • Evaluation of evaluations (peer-review)• Knowledge/Research uptake “strategy”?

UHC?

• What to provide? How much?• How to provide?• For whom?• Who decides these questions? And by what

process? • How do we measure /assess progress with respect

to these above questions?

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Service A Service B Service C

People in need Received service Service and no financial hardship

Inpatient Outpatient Deliveries

Total utilization 455 494 186

Public 265 264 176

Private 190 230 10

50

150

250

350

450

550

Inpatient Outpatient Deliveries

Public 2300 120 225

Private 10800 1000 8750

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3000

5000

7000

9000

11000

IS THERE AN IDEAL ASSESSMENT FRAME-WORK?

• Framework is important• Six pillars (health systems functions)

• Performance Criteria

• Ref: (Health systems 20/20. 2012. The Health System Assessment Approach: A how-to manual version 2.0 (www.healthsystemassessment.org)

Building blocks interactions(www.healthsystemassessment.org)

KEY INDICATORS: FINANCING(WWW.HEALTHSYSTEMASSESSMENT.ORG)

• THE as % of GDP• Per capital total health expenditure • Govt. expd on health as % of THE• External resources as % of THE• OOPs as % of THE• Population coverage of health insurance

• Multiple/disaggregated indicators should be developed (rural/urban/service oriented, etc)

PERFORMANCE INDICATORS FOR HEALTH FINANCING (HSAA, 2012)

• Equity (OOPs as % of THE; policies for user-fees, informal payment, etc)

• Efficiency (Process of MoH budget formulation, local level spending and institutional capacity, contracting mechanisms; etc)

• Access (user fees, informal payment, population coverage of health insurance, etc)

• Quality (govt. spending as % THE, contracting mechanisms, • Sustainability (budget allocations, level of decentralisation,

process of budget allocation, etc)

• Recent PoE/IEG study, NRHM, 2012) covers a range of issues; long way to go as per “Six Pillars/Performance Criteria” framework

KEY INDICATORS: HRH(WWW.HEALTHSYSTEMASSESSMENT.ORG)

• Current HRH situation• Policy and Planning • HRH management system• Financing of HRH• Education and Training• Leadership of entire HR

CONCLUDING REMARKS

Cadres of researchers• Who can do what? (academic/university based; advocacy

action research; Think-Tanks (NHSRC, IPH, within Govt Evaluation cells; etc) Short term, medium term, long term research)

• “Implementers and evaluators” (what do they say?)

Implementation Research:

• “ Implementation Research” (focus on processes, encourage the open-box approach, rather than outcomes/outputs alone. “Eg: “How do we assess whether an incentive has worked?” Should we merely use the performance and make conclusions? • Ssengooba F. et al (2012) “why performance based contracting

failed in Uganda? An open box evaluation of a complex health system intervention” social science and medicine 75 (2012)

CONCLUDING REMARKS

• Building stronger bridges between implementers and evaluators (Mills, et al 2012, Chapter 16)

• Researchers/Evaluations from Design stage rather than at the final stage of evaluation

• Insist on Publication of Evaluation Research: Per-reviewed processes are a must….they should be viewed as a part of the democratic process….”in the knowledge creation and knowledge uptake process”…..

0

10

20

30

40

50

60

70

80

90

100

Service A Service B Service C

People in need Received service Service and no financial hardship

Inpatient Outpatient Deliveries

Total utilization 455 494 186

Public 265 264 176

Private 190 230 10

50

150

250

350

450

550

Inpatient Outpatient Deliveries

Public 2300 120 225

Private 10800 1000 8750

1000

3000

5000

7000

9000

11000

THANK YOU