Health System Performance Comparisons of Financial Protection by hcj

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									     Improving the Measurement of
         Financial Protection in
            Health Systems
             Dr Rodrigo Moreno-Serra
   Centre for Health Policy, Imperial College London
            r.moreno-serra@imperial.ac.uk


PCPH, Imperial College London, 5th October 2011
                 Background
• Financial protection (FP): extent to which
  people are protected from the financial
  consequences of illness
  – Key objective of health care (HC) systems,
    multidimensional
  – Financial hardship and lack of access to HC due to
    costs still widespread (WHR 2010)
  – FP may suffer in a context of economic downturn
  – Monitoring FP is crucial for sound health policy
 FP measurement: where are we?
• Focus on households’ living standards before
  and after direct payments for health (OOPs)
• OOPs reported in household surveys
Catastrophic spending
  – OOPs cross set threshold in terms of share of
    disposable income
Impoverishing spending
  – OOPs push household income below a chosen
    poverty line
          FP metrics: criticisms
1. Measurement of capacity to pay, effects of
   lost income etc...
2. Effect of financial barriers to access: the
   elephant in the room
  – Ability to pay may deter access to necessary HC
  – Linked to equity but indicator of FP extent
  – Sole focus on incurred spending may provide
    misleading picture of FP
     Catastrophic spending incidence and DTP3 immunization
     coverage among 1 year-olds, 87 countries (various years)




Source: Immunization data from WHO. Catastrophic spending incidence data from Xu et al. (2007). Financial
catastrophe is defined as OOPs for health reaching at least 40% of a household’s non-subsistence income.
                                                    Financial barriers to access in high-income countries
                                                        with low incidence of financial catastrophe
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Had problems with access because of cost (%)




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                                                       Source: IHPS, Commonwealth Fund (Schoen et al. 2010).
 Financial Protection Measures:
Suggested Areas for Development
   I. Complementing conventional
            FP indicators
• Coverage indicators
   –   WHR 2010
   –   Generally feasible route
   –   But often limited information available
   –   Role of various other determinants of coverage levels
• Access surveys
   – E.g., IHPS (Commonwealth Fund), World Health
     Surveys (WHO), LSMS (World Bank)
   – Need implementation on routine and comparable
     basis
       II. Improving conventional
              FP indicators
• ‘Need-adjusted’ FP metrics
   – Estimate expected utilization and OOPs according
     to ‘medical need’ characteristics
   – Adjust catastrophic and impoverishing spending
     incidence (expected incidence)
   – May yield very different policy conclusions from
     conventional analysis (e.g., Pradhan and Prescott 2002)
   – But methodologically challenging
      III. An exploratory tool:
 Data Envelopment Analysis (DEA)
• Based on economic concept of production frontier
• Through linear programming, find units that achieve
  same (or better) outputs at lower use of inputs

                              • Efficiency = actual/optimal
                                performance (OQA/OQ1)
                              • Can examine efficiency
                                based on multiple outputs
                                (e.g., FP indicators) and
                                inputs
  DEA applied to FP assessment
• Question: How do developing countries compare
  concerning efficiency in ‘producing’ FP given available
  resources (constraints)?
• Criteria for efficiency analysis: FP indicators relative to
  total health spending (THE) per capita (input orientation)
• Gets at the issue of achievable FP performance

Financial protection proxy                     Mean     Std. Dev.   Countries
Protection against catastrophic spending (%)    96.9      2.7          58

Median immun. coverage (6 vaccines) (%)         84.4      11.8         58

Births attended by skilled personnel (%)        73.6      27.4         58

THE per capita (PPP, constant 2005 US$)        253.49    244.93        58
DEA applied to FP assessment
DEA applied to FP assessment
           Concluding remarks
• Financial barriers: distorting effects on
  conventional FP assessments
• Despite recent progress, we need better FP
  metrics for:
  – Policy guidance
  – International performance comparisons
• Huge potential gains from a health policy
  perspective

								
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