1. Benchmarks of Fairness for Health Sector Reform in Developing Countries: Overview Norman Daniels PIH, HSPH Ndaniels@hsph.harvard.edu

2. –The Adapted Benchmarks –1. Intersectoral public health –2. Financial barriers to equitable access –3. Nonfinancial barriers to access –4. Comprehensiveness of benefits, tiering –5. Equitable financing –6.Efficacy,efficiency,quality of health care –7. Administrative efficiency –8. Democratic accountability, empowerment –9. Patient and provider autonomy

3. Connections to social justice Equity –B1Intersectoral public health, B2-3 Access, B4Tiering, B5 Financing Democratic Accountability –B8, B9Choice Efficiency –B6 Clinical Efficacy and quality –B7 Administrative efficiency

4. Structure of BMs B1-9 Main Goals –Criteria -- Key aspects Sub criteria-- main means or elements Evidence Base + Evaluation –Indicators –Scoring Rules

5. WHO Framework vs BM complementaryMove to reformsOverlap Subjectivity?Inform change?Problems Info, tr. peopleGood infoRequires VariousNational pol mkWho uses ScoresIndex, ranksProduct DeliberateMotivatePurpose Reform evalCurrent performObjective Nat, subnatCross nationalScope BMWHO

6. B1: Intersectoral Public Health Degree to which reform increases per cent of population (differentiated) with: basic nutrition, adequate housing, clean water, air, worplace protection, education and health education (various types), public safety and violence reduction Info infrastructure for monitoring health status inequities Degree reform engages in active intersectoral effort

7. B2: financial barriers to access Nonformal sector –Universal access to appropriate basic package –Drugs –Medical transport Formal Sector Social/Private Insurance –Encourages expansion of prepayment –Family coverage –Drug, med transport –Integrate various groups, uniform benefits

8. B3: Nonfinancial barriers to access Reduction of geographical maldistribution of facilities, services, personnel, other Gender Cultural -- language, attitude to disease, uninformed reliance on traditional practitioners Discrimination -- race, religion, class, sexual orientation, disease

9. B6: Efficacy, efficiency and quality of health care Primary health care focus –Population based, outreach, community participation, integration with system, incentives, appropriate resource allocation Implementation of evidence based practice –Health policies, public health, therapeutic interventions Measures to improve quality –Regular assessment, accreditation, training

10. B8: Democratic accountability and empowerment Explicit public detailed procedures for evaluating services, full public reports Explicit deliberative procedures for resource allocation (accountability for reasonableness) Fair grievance procedures, legal, non-legal Global budgeting Privacy protection Enforcement of compliance with rules, laws Strengthening civil society (advocacy, debate)

11. Why is evidence base important? Evidence base makes evaluation objective Making evaluation objective means: –Explicit interpretation of criteria –Explicit rules for assessing whether criteria met and the degree to which alternatives meet them Objectivity provides basis for policy deliberation –Gives points of disagreement a focus that requires reasons and evidence

12. Evidence Base: Components Adapted Criteria--convert generic benchmarks into country-specific tool –Reflect purpose of application –Reflect local conditions Indicators –Outcomes –Process –revisability Scoring rules –Connect indicators to scale of evaluation –Specify in advance

13. Process of selecting indicators Clarity about purpose Type of criterion determines type of indicator –Outcomes vs process indicator appropriate –Standard vs invented for purpose –Requires clarity about mechanisms of reform Availability of information Consultation with experts Final selection in light of tentative scoring rules Further revision in light of field testing

14. Scoring Benchmarks Reform relative to status quo -50 +5 Or use qualitative symbols, --- or +++

15. Scoring Rules: General Points Map indicator results onto ordinal scale of reform outcomes Final selection of indicators should be done as scoring rules are developed, so refinements can be made Scoring rules should be adopted prior to data collection to increase objectivity, but may have to be revised in light of problems

16. Two approaches to evidence Thailand: survey of various groups judging based on discussion of evidence Strengths: range of views, involvement of larger groups Weakness: vaguer basis for judgment? Guatemala, Cameroon: team evaluation based on indicators, scoring rules Strengths: clarity about evidence base for evaluation Weakness: trained team, narrow input

17. APHA Later Thailand Guatemala Cameroon Zambia--HIV/AIDS Yunnan, China-rural reform Ecuador, public health, comprehensive Vietnam-comprehensive reform Pakistan- community use Chile, Nicaragua, Sri Lanka, Nigeria (ACOSHED), Bangladesh

18. Plans for Benchmarks Research Network for all sites, other efforts at monitoring reform Funding for country level projects using adapted benchmarks Coordination with WHO, regional organizations of WHO, World Bank, USAID