Mexico Covertura Oms

8/3/2019 Mexico Covertura Oms

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Benchmarking Performanceof Mexican States Using

Effective Coverage

Rafael Lozano, Patricia Soliz, Emmanuela Gakidou, JesseAbbott-Klafter, Dennis M Feehan, Cecilia Vidal, Juan

Pablo Ortiz, Christopher JL Murray

Health System Metrics

Glion, SwitzerlandSeptember 28-29 2006


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Outline

Background

Effective coverage at sub-nationallevel Selecting interventions

Measurement strategies

Results

Selected interventions Health system effective coverage

Lessons learned


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Background

National Health Program 2001-2006

Goals, Strategies and Activities

Health Reform in Mexico 2004-2010 Formula for resource allocation

WHO HSPA framework 2000 and newversions


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Information and Local Capacity

National Health surveys

World Health Survey

National survey of health system performance(2002)

Administrative records

Links from the MOH with HIGH and N

IPH

Publications, workshops


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States 32

Counties2.4 thousandsLocalities199 thousands

Mexico 2005

7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0

0-4

5 a 9

10 a 14

15 a 19

20 a 24

25 a 29

30 a 34

35 a 39

40 a 44

45 a 49

50 a 54

55 a 59

60 a 64

65 a 69

70 a 74

75 a 79

80 a 84

85 +

Males Females

Population Million 106.5

Males 51.8

Females 52.4

% with health insurance 56.2

% without health insurance 43.8

% Urban Areas 74.7% Rural Areas 25.3

Mexico 2005


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Health Change in Mexico

0%

20%

40%

60%

80%

100%

1950 1960 1970 1980 1990 2000 2010 2025

Communicable Non Communicable Injuries

Causes of death transition

0%

20%

40%

60%

80%

100%

1950 1960 1970 1980 1990 2000 2010 2025

0-14 15-65 65+

Age pattern


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Mexico Health System (2005)

Fragmented Insured Inst, Non Insured Inst, Private

Decentralized

Since 80s

Financial Unbalances

534.2218**109**1,511106*Total (absolute)

1,000.029.830.426.52.8Private

216.88.5Popular Insurance

910.03.65.27.91.5Others

231.97.06.27.07.5ISSSTE

324.829.926.823.135.8IMSS

325.630.538.338.056.2With medical Insurance

87.929.731.435.543.8No medical insurance

Expenditure

per

PercapitaUSDPhysicians%Beds%Hospitals%

Popu-

Lation%

* millions, ** thousands


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Outline

Background

Effective coverage at sub-national level

Selecting interventions Measurement strategies

Results


Lessons learned


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Effective coverage is the synthesis of threeanalytical approaches in the study of coverage

of health services

Sociological

Studies about access to

health services,utilization, identification of

barriers

Economics

Studies about health caredemand concerning prices,

quality, distance, etc.

Public health

Studies of the proportion

of the population that

receives an intervention


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Effective Coverage the fraction of potential health gain that

can be delivered through an interventionby the health system that is actuallydelivered

Steps for EC Measurement

1. How do we identify the groupwho needs an intervention?

2. How do we identify those who

need an intervention thatreceived one?

3. How do we measure quality ofthe intervention delivered?

Defining the set of interventions

affordability,

total population health gain

impact on health inequalities.

whether a measurementstrategy for the intervention

can be developed


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Table 1: Selected interventions for the measurement of EC in Mexico

Intervention Definition

Effective coverage of measles* % of children 1-4 that have been vaccinated against measles

Coverage of DPT3* % of children 1-4 that have been vaccinated with DPT3

Coverage of BCG* % of children 1-4 that have been vaccinated against BCG

Coverage of breast cancer screening % of women 40-69 that had a mammography in the last year

Coverage of cervical cancer screening % of women 25-69 who had a pelvic exam in the last year

Coverage of antenatal care

% of women that had 4 or more checks and blood, urine, pressure

tests during last pregnancy

Coverage of skilled birth attendance % of women that had their last birth attended in hospital

Coverage of treatment of premature

newborns death rate among newborns 30-34 weeks of gestational age

Flu vaccine Adults over the age of 60 have been vaccinated in the lasy year

Coverage of treatment of diarrhea % of children under five that received ORS or more liquids during

last episode of diarrhea in the last month

Coverage of treatment of ARI

% of children under five for which advice was sought from a health

personnel in the last episode of fever/cough/pneumonia in the

last month

Effective coverage of treatment of vision

disorders

% of people who need glasses that have glasses that solve their

vision problems

Coverage of treatment of High Cholesterol

Adults >20 years with total cholesterol equal to or greater than

200mg/dl

Effective coverage of treatment of

hypertension

% of people with high blood pressure that received appropriate

treatment

Normative

Biological

m

arkers

Oneors

everal

sympt

oms


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Measuring effective coverage in Mexico

This exercise was carried out by the Ministry of

Health (General Direction of Health Information), theNational Institute of Public Health and HarvardUniversity (HIGH)

The information sources basically come from theENSA 2000, ENED 2002, ENSANUT 2005-06,

administrative registries and vital statistics Effective coverage has been measured for 8

interventions and coverage for 18 interventions

Effective coverage has been estimated by state but not by health care provider

A composite measure of effective coverage wasestimated

The precision on each of the indicators vary accordingto the quality of the data source


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Outline

Background



Results


Lessons learned


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Visual Impairment correction

Definition

Effective coverage for visual impairment is defined as the proportion of adultsover the age of 20 with visual impairments that have glasses or contacts thatsolve their vision problems.

How was need estimated? Need for correction of visual impairments is measured in the ENSANut 2005-06

by self-reports of difficulties on two items in the survey. This module of thesurvey was only applied to respondents over the age of 20 and included twoquestions on difficulties with vision. All individuals responding that they had any

visual difficulties were included as needing correction. How was utilization estimated?

Utilization is calculated using self-reported use of glasses or contacts.

How was quality estimated? Quality has been estimated using the items in ENSANut 2005-06 on difficulties

with near and far-vision using glasses or contacts. Any individual who reportsno problems on both questions in the survey is counted as having effective

coverage. We have not weighted the measure by the magnitude of problemsreported so this is not a direct measure of the fraction of health gain deliveredby the intervention. This measure also suffers from all the comparabilityproblems that plague any measure of self-reported functional health.


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Crude and effective coverage* of visual impairment correction for

Mexican states and Distrito Federal, 2005-2006.

0%

20%

40%

60%

80%

100%

Oax

Chis

Tlax

Mich

Tab

Gro

Gto

Hgo

Pue

Ver

Slp

Mor

Nay

Camp

Dgo

Sin

Jal

Qroo

Zac

Ags

Col

EUM

Yuc

Qro

Bcs

Son

Chih

Mex

BC

Coah

Tamp

NL

DF

Crude Coverage

Effective Coverage

*95% confidence intervals


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Services delivered to premature newborns

Definition The fraction of the maximum possible health gain that can be delivered to

moderately premature newborns that is actually delivered. The maximum health gainwas constructed as the difference between the expected upper and lower bound fordeath rates conditional on gestational age and birth weight.

How was need estimated? All moderately premature newborns in Mexico; moderately premature has been

defined as gestational age between 28 and 36 weeks and birth weight less than3500g.

How was utilization estimated?

We have used the same dataset to define utilization of hospital services forpremature newborns as we have used for need.

How was quality estimated? The difference in the observed mortality rate among premature newborns compared

to the maximum and minimum mortality rates conditional on gestational age andbirth weight that could be observed. Maximum mortality rates has been constructed from the neonatal mortality rates,

conditional on birth weight and gestational age, recorded in the US in 1950 (2): in 1950,

effective interventions for premature newborns were not yet available at that time so thisrepresents a reasonable approximation of no care.

The lower bound for death rates was estimated based on a regression analysis of thestandard of care for premature newborns conditional on gestational age and birth weight inthe states of Massachusetts, New York, and New Jersey in 2000-2002, which have thelowest conditional mortality rates in the US.


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Effective coverage of services delivered to premature newborns in Ministry ofHealth hospitals and 95% confidence intervals, 2004-2005 by Mexican state.

0%

20%

40%

60%

80%

100%

Gro

Oax

Pue

Bcs

Chis

Mor

Coah

Ver

Mex

Col

EUM

Gto

Zac

Camp

Tlax

Hgo

Jal

Mich

DF

Tab

Son

NL

Qroo

Chih

Slp

Sin

Nay

Dgo

Tamp

BC

Qro

Yuc

Ags


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Treatment of Hypertension Definition

The ratio of actual systolic blood pressure reduction from treatment ofhypertension to potential blood pressure reduction.

How was need estimated? In the estimation of effective coverage, need of treatment is defined as a level of

blood pressure equal or above a threshold of 140 mmHg. The information onlevels of blood pressure is taken from the ENSANut 2005-06 survey, whichrecords for each individual aged 20 and above two measurements of systolicblood pressure (SBP), taken five minutes apart. The prevalence of the conditionis estimated using an average of the two measurements.

How was utilization estimated? The ENSANut 2005-06 provides state representative data for the analysis ofblood pressure including self-reported information on treatment with medication.An individual is considered to be on treatment for hypertension if he or shereports currently taking medication to control his or her level of blood pressure.

How was quality estimated? In the first stage of the analysis, we use logistic regression to model the

probability of a respondent reporting being on anti-hypertensives as a function of

age, sex, bmi, speaking an indigenous language, household wealth, and level ofeducation, in addition to our two instruments: insurance status and the crudecoverage of hypertension in the respondents community. Results of the first-stage IV analysis show that both instruments are highly predictive of theprobability of treatment: the area under the models ROC curve is 0.84.

In the second stage analysis we use linear-normal regression to model bloodpressure as a function of the predicted probability of being on antihypertensives,as well as the set of non-instrumental covariates used in the first stage. The

second stage results suggest a treatment effect of 11mmHg.


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Crude and effective coverage and 95% confidence intervals of treatment

for hypertension in Mexican states and Distrito Federal, 2005-2006.

0%

20%

40%

60%

80%

100%

Qr

o

Yu

c

Ve

r

Gr

o

Cam

p

So

n

Hg

o

Qro

o

Si

n

Pu

e

Za

c

Mic

h

Ta

b

Bc

s

Tla

x

Na

y

Chi

s

Dg

o

EUM

Chi

h

Coa

h

Sl

p

Oa

x

Mex

Col

N

L

Ag

s

Gto

BC

Tam

p

D

F

Mor

Jal

Crude Coverage

Effective Coverage


20/31rageof

CervicalCance

rScreening,

M

xico2000-200

5

Que

Mo r

N L

S lp

Me x

Gro

Yu c

BC

EUM

DF

Bcs

Ja l

Gto

D go

Pue

C amp

T lax

Ags

S in

Zac

Oa x

Ve r

H g o

C o l

N a y

Qroo

Tab

Ch i s

ENSA2

000

ENSANut2005


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Coverage of Cervical Cancer Screening, Mxico 2000 -2005

Insurance Income Quintile

0%

10%

20%

30%

40%

50%

60%

Uninsurance Seg Popular Private Soc Insurance

ENSA 2000 ENSANut 2005

0%

10%

20%

30%

40%

50%

60%

1 2 3 4 5

ENSA 2000 ENSANut 2005


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Constructing Effective

Coverage Composites following the formal definition of effective coverage,

each intervention could be combined in proportion to theaverage health gain it delivers to the population;

preference weights can be derived from revealed choicesin the marketplace or from survey responses; arbitrary weights such as simple averages or other

weights can be used; one can assume that each indicator is an imperfect

measure of an underlying unobserved construct, healthsystem effective coverage, and use latent variabletechniques such as factor analysis or variants of probitsand logits.


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0%

10%

20%

30%

40%

50%

60%

Gro

Oax

Chis

Pue

Mich

Ver

Bcs

Mor

Sin

Tamp

Slp

Chih

EUM

Qro

BC

Son

Tlax

NL

Col

Zac

Mex

Jal

Coah

Hgo

Comp

Inde

EffeCove


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0%

20%

40%

60%

80%

100%

1 2 3 4 5

Quintile of Wealth

CompositeEffectiv

eCoverag

Maternal andChild Health

Other

Interventions

All Interventions

Composite effective coverage (14 interventions), maternal and childhealth intervention coverage (8 interventions) and other adult

interventions coverage (6 interventions) by household wealth quintile,Mexico 2005


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Composite effective coverage (14 interventions) for 2005by

state, versus the log of public health expenditure per capita.

40%

45%

50%

55%

60%

65%

70%

6.0 6.5 7.0 7.5 8.0 8.5 9.0

Ln expenditure 2005

EC

2005


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Change in effective coverage for 8 interventions measured in 2000 that are strictlycomparable to 8 interventions measured in 2005, by state, compared to the percentincrease in public spending per capita over the same time period. respiratory infection,diarrhea, cervical and breast cancer screening, skilled birth attendance, hypertension, services

delivered to premature newborns, and antenatal care.

-5%

0%

5%

10%

15%

20%

25%

30%

0% 10% 20% 30% 40% 50% 60% 70% 80%

% change in expenditure, '00 to '05

%

changeincomparable

EC,

'00-'05


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Outline

Background



Results


Lessons learned


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Lessons for Mexico

Mexico is the first country to fully implement therecommendation to measuring EC at subnationallevel

The relation between public health spendingpercapita and EC highlights the importance ofraising levels of spending per capita in thedisadvantaged states

EC allows us to say than Mexico has two health

systems, one for MIC and other for NonCommunicable diseases and injuries

Improve HIS and build local capacity(investment)


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Implications for the Mexican HealthInformation System

More attention in future to measuring quality of interventiondelivery.

Examination surveys produce hard endpoints in which toanchor the analysis.

Careful attention in developing better measures of effective

coverage, for example Diabetes. Further work is needed to characterize the biases inadministrative data for measuring effective coverage of someinterventions.

A comprehensive information's system needs to harmonizedata collection for certain interventions across all institutions

of public sector and even private. Because of the potential of pharmacological strategies for

hypertension, cholesterol and possibly blood sugar (diabetes),prospective registries of treatment impact should bedeveloped.


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Global Lessons

Updating the philosophy of HS How much health gains is delivering the HS?

Another way to measure access to health facilities

EC shifts the focus to achievements

Strengthening the economic analysis of HS resources

Affects the four HS functions

To revise the scope of the agenda: MDG+ framework(focusing in monitoring EC of interventions for non

communicable and injuries)


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Mexico Covertura Oms

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