Benchmarking Fairness in Reproductive Health

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1 Department of Reproductive Health and Research, Family and Community Health Cluster in collaboration with Evidence and Information for Policy Cluster Paper Prepared for Technical Consultation on Health Sector Reform and Reproductive Health: Developing the Evidence Base Geneva, 30 th November- 2 nd December 2004 Benchmarking Fairness in Reproductive Health Norman Daniels, PhD Professor of Ethics and Population Health Harvard School of Public Health Walter Flores, MCommH Research Associate Universidad de San Carlos de Guatemala Jesica Gomez- Jauregui, PhD Research Associate National Institute of Public Health Cuernavaca, Mexico Note: The views expressed in this document are those of its authors and do not necessarily represent those of WHO

2 Benchmarking Fairness in Reproductive Health Presentation to Consultation on Health Sector Reform, Equity and Reproductive Health, Geneva, Dec 1, 2004 Norman Daniels, Ph.D. Corresponding Author Professor of Ethics and Population Health Harvard School of Public Health Dept. Population and International Health Walter Flores, MCommH, Research Associate Universidad de San Carlos de Guatemala Jesica Gomez-Jauregui, PhD Research Associate Center for Health Systems Research National Institute of Public Health Cuernavaca, Mexico Funding Support: Daniels: Rockefeller Foundation (HE 070); Flores: European Union Grant (No. ICA4-CT ) and CARE-Guatemala. Acknowledgments: Fidel Arevalo, Ministry of Health-Baja Verapaz (Guatemala), CLEPS/UNL and ALDES (Ecuador). 1

3 Benchmarking Fairness in Reproductive Health Norman Daniels, PhD Walter Flores, McommH Jesica Gomez-Jauregui, PhD Presentation to Consultation on Health Sector Reform, Equity and Reproductive Health Geneva, Dec 1, Overview We begin with some brief conceptual and ethical remarks about the concept of equity in reproductive health. These are a necessary precursor to our main task, which is to propose a method for monitoring and evaluating the equity, accountability, and efficiency of reproductive health policies and reforms. We use the term fairness to refer to the integrated concern about equity, accountability, and efficiency. The benchmark method combines an ethically integrated framework for thinking about these three central goals of health reform with an evidence base constructed out of carefully adapted criteria and indicators to measure their satisfaction. We then present three examples of efforts to apply the benchmarking approach to reproductive health issues. Two of them involve work in Guatemala and Ecuador carried out by Walter Flores and an interdisciplinary team of collaborators examining several health policies related to reproductive health. The second case involves work by Jesica Gomez-Jauregui, who has adapted the benchmarking approach to examine equity issues in the delivery of cervical cancer screening in Mexico. We conclude with some lessons learned from these cases that bear on generalizing this approach to other contexts. 2. Equity and Fairness in Reproductive Health Fairness includes equity. But there are two central issues of equity in reproductive health, gender equity and equity across other demographic groups. It is important to attend to both. 2.1 Gender equity A central concern of gender equity is whether adequate attention is being paid to the distinctive health needs of women, whether we are concerned with reproductive health or other aspects of women s health. Sometimes women s health is distinguished from gender equity because gender equity is construed too narrowly. On this narrow view, it is concerned with differential outcomes from (disease specific mortality rates or infant mortality rates) and differential access to treatment for similar health conditions (e.g. heart disease or nutrition). We understand gender equity more broadly and see women s health as one component of gender equity. Our reason for preferring the broad view goes back to our reasons for thinking we have social obligations to protect health and provide equitable access to care. One of us (Daniels 1985, Daniels et al 1996), argues that protecting health is of special importance because of its impact on the 2

4 opportunities open to individuals and groups. If we have social obligations to assure people of fair equality of opportunity, then we must protect health. This means meeting the health needs of both men and women, attending equitably to both divergent and convergent needs. The special health needs of women, both reproductive and otherwise, must be addressed, and where there are convergent or similar needs, access to the resources for meeting those needs must be equal across genders. These resources include the fair distribution of the social determinants of health including education, effective political participation, adequate nutrition as well as of public health and personal medical services. Achieving gender equity regarding reproductive health also means shifting from a narrow focus on women and the measures that they may take, for example, to practice safe sex or to control birth rates, to a broader focus that includes male responsibilities in these activities and obligations to grant women autonomy. The health sector is a place where those obligations and responsibilities must be addressed if equity is to be achieved. 2.2 Other demographic inequities in reproductive health Equity in reproductive health must also be concerned with disparities in outcomes and access across other demographic groups by income and education level, by geographical location, by ethnic or religious background, or other specially vulnerable populations (the homeless, people with disabilities). Here, as in the case of gender equity, there are inequities created by several factors: unequal access to services of comparable quality, in part the result of ineffective health policies, inequalities in risk reduction through public health measures, and, upstream of the health sector, through inequalities in the social determinants of health. Each of the situations above is represented in the three country cases presented in a later section. The benchmarks approach gives attention to both kinds of equity in reproductive health, though each poses quite different problems of measurement. Both also require intersectoral efforts that are sometimes ignored in reproductive health policies and programs. 2.3 The connection between equity, accountability, and efficiency Our interest in equity follows from various views about justice and human rights in health and health care. In focusing on equity, we risk ignoring to other aspects of social justice that should be addressed, accountability and efficiency. Efficiency is important because all systems have limited resources. More efficient systems can get better value for money in meeting needs. Provided attention is paid to making efficiency work in the pursuit of equity, these two ideas need not conflict. Accountability has only recently been attended to, since it has become clearer that lack of good governance in systems undermines efficiency. It also undermines legitimacy in these systems people lose confidence (if they ever had it) that the system aims to meet their ends. Accountability, like equity, is intrinsically important: we have a fundamental interest in knowing why decisions that affect our well-being in fundamental ways are made the way they are. Accountability of providers and managers is a necessary condition for controlling democratically the systems that meet our needs. 3

5 3.The Benchmarks of Fairness 3.1 History The Benchmarks grew out of work early in the 1990s to develop a matrix for assessing the fairness of health insurance reform in the United States (Daniels & Brock 1994; Daniels et al 1996; Daniels 1998). In 1999, teams from Pakistan, Thailand, Mexico and Colombia, all of which had undertaken recent health sector reforms, met to adapt the original matrix into a generic developingcountry framework (Daniels et al 2000). Despite the different cultural and social histories and levels of development in the collaborating sites, teams arrived at a generic matrix for assessing the fairness of reform efforts. Specifically, the teams agreed upon nine main Benchmarks (see Table 1). Each benchmark specifies a key objective of fairness and has criteria capturing important elements of these objectives and means of achieving them. The criteria emerged in the four-country adaptation process that focused on case studies of recent reforms and problems in those systems. The nine generic benchmarks integrate the goals of fairness as follows: B1-5 address equity; B6-7 consider efficiency; B8-9 concern accountability (see Table 1). 3.2 Structure and Function The Benchmarks of Fairness combines familiar operations research methods for assessing progress with a framework that focuses on these key goals. The Benchmarks method asks how much a reform improves or worsens aspects of fairness within the health sector. The changes are measured relative to a baseline, taken to be the status quo when reforms are introduced, using appropriate indicators. Due to gaps in data, the baseline will have to be set during the first application of the benchmarks. This multi-dimensional comparison of the status quo to changes allows for an evidence-based evaluation of reproductive health policies and reforms. The evidence base, integrated with an ethical framework, enhances capacity for deliberation about the goals and mechanisms of reform. 3.3 Local Application The generic benchmarks and criteria must be adapted locally by an interdisciplinary team. An evidence-based application aims to refine the generic criteria, specify indicators appropriate to local conditions, and achieve agreement on how to evaluate changes in these indicators. Applying the benchmarks then enables planners or community groups to evaluate the impact of health policies. By providing an evaluation methodology that rests on locally accessible information, teams can ameliorate current practice, which often involves little evidence-based evaluation of proposals to improve the health of disadvantaged people. A typical interdisciplinary team consists of policy makers, academics, health system personnel, clinicians and stakeholders. The breadth of the benchmarks compels people with different training to look across disciplinary boundaries and brings together people from various levels in the health system to understand their different views. 4

6 The team must consider how to adapt the generic criteria for their use in examining issues surrounding equity, accountability, and efficiency in reproductive health. We shall return to details of this process in the next section. The team must also pay attention to the sources of information for different indicators. In many cases there is good data for traditional indicators bearing on some measures of health outcomes and some kinds of utilization. For indicators bearing on accountability, intersectoral cooperation and quality measures, countries have had to use non-standard sources of information or qualitative techniques. 4. Applying the Benchmarks to Reproductive Health 4.1 GUATEMALA A team of academics, members of the ministry of health, and an NGO have been cooperating during the last two years in Baja Verapaz province (north region of Guatemala) to develop a special adaptation of the benchmarks that focus on the effects of recent policies (mainly decentralization, financing, and improving access to basic packages of services) on the delivery of public health services (Daniels & Flores 2004). In this adaptation, reproductive health is included as a central component of public health. In addition, several key reproductive health services were used as tracer indicators to help measure whether equity in public health (including reproductive health) is being improved or worsened as result of policy reforms. The indicators and measurement tools use routine information available from MoH s health information system. These range from simple but highly relevant analyses of the non-financial barriers that may impede access to services, such as the language skills and gender of health care providers, to more elaborate measures. These composite measures combine coverage of basic health care services with an analysis of key institutional and community resources available to deliver and achieve public health targets, including reproductive health. To illustrate the importance of non-financial barriers to access, consider the context. It is estimated that more than 70% of the population in Baja Verapaz province are indigenous, speaking one of the several native (Mayan) languages. Though many inhabitants can also communicate in Spanish, significantly fewer woman can. Data collected for the year 2002 (see table 2) reports that less than 10% of doctors in the region are female. In addition, none of the medical doctors speak any of the native languages. These two factors already pose a cultural barrier for indigenous women seeking health care: they may be reluctant to go to men, especially ones they cannot communicate with. Community health facilitators have better familiarity with indigenous languages, since they often share ethnicity with the people served. But the skills and training of this level of community health worker for dealing with health care problems is quite limited. Their duties primarily involve health care promotion and some basic preventive services. 5

7 Some key reproductive health services were used in constructing measures of inequities in public health in Baja Verapaz Province. One such service is the provision of qualified assistance during delivery 1. Using data from the year 2003, the analysis showed a serious shortfall in this region: one fifth of all deliveries fulfilled the national norm (assistance by medical personnel). To establish the extent of the health inequity, we analyzed the distribution of attendance during delivery by different providers in the different districts of that province. This analysis is presented in Figure 1. In Figure 1 we observe wide disparities in access to qualified assistance in deliveries. The districts of Salama and San Jeronimo have the largest concentration of deliveries attended by medical staff, whereas in districts such as Chicaj, Purulha and El Chol, the coverage of qualified attendance during delivery is less than 5%. Our analysis also aimed to measure disparities in the prevalence of low birth weight in the different districts. We also wanted to determine whether the low birth weight was registered more frequently in those districts in which women were attended by medical staff. Figure 2 shows that the district of Salama, although accounting for only for 22% of all deliveries, had 60% of all deliveries attended by medical staff. At the other extreme, Cubulco district, which had 24% of all deliveries in the region, had only 5% of all those attended by medical staff. This analysis reveals a serious inequity in access to qualified attendance during delivery in Baja Verapaz region. Medical assistance for deliveries is concentrated in Salama district, where the regional hospital is located. An important, and seemingly more paradoxical, finding is that low birth weight is also concentrated in those districts that have a higher percentage of deliveries attended by medical staff. The paradox of higher prevalence of low birth weight correlated with better access can be explained by saying that birth weight is either not registered, or is inadequately assessed, in those deliveries attended by non-medical staff (TBA s and relatives). If this explanation can be supported by more direct assessment of record keeping, then we should not infer that low birth weight is not a problem in districts with less access to properly attended deliveries. Rather, there probably is a serious underestimation of low birth weight in the region. The team also developed indicators and more complex indices intended to measure inequitable access to basic public health services. Specifically, three indices were developed, an index for priority of health care services (IPHS), an index of resource distribution (IRD) and an index of human resources (volunteers) available at health district level (IRRHHCo). The IPHS combines the coverage for three basic services (immunization, antenatal care and qualified attendance during deliveries) understood as tracers of public health services. The bigger the gap between actual and ideal coverage for these services, the higher the priority score (on a scale from 0.01 to 0.99). The formula to estimate the index value is presented in Table 3. 1 Statistics in Guatemala collect information on attendance by medical staff (doctor or nurse) as a proxy of qualified personnel. 6

8 The index of resource distribution (IRD) gives a higher score (on a scale from 0.01 to 1.0) the more resources per capita are available in a district. It combines a weighted measure of three tracer resources (non-salary health expenditures for primary care, health personnel, and health facilities). Districts with the most resources in each indicator serve as comparison (or ceiling) for the other districts 2. The formula to estimate the index value is presented in Table 4. The Guatemalan study also included an index of availability of human resources (volunteers) at community level (IRRHHCo) The index is calculated in a similar way as the index of resources (IR) but the indicators are replaced by the following: # health promoters per 1,000 inhabitants; # of traditional birth attendants by 10,000 inhabitants and % of communities within each district that are organized in health committees. The formula to calculate the index is in Table 5. The higher the value (between 0.01 and 1.0), the larger the network of community volunteers available in a given district in comparison with the rest of the districts. A low value implies a reduced/weak network of community volunteers in a given district. The first application of these indices compares IPSS versus IR. If there were an equitable distribution, then more resources should be given to districts with greater need, that is, a greater shortfall in delivery of the indexed services. Districts with high priority scores would be the same ones receiving higher resource scores. Figure 3 shows the mismatch in actual coefficients for districts in Baja Verapaz province using data for year San Miguel Chicaj and Cubulco are the districts with the highest coefficients for priority (solid bars). Despite this, these two also are the districts receiving the lowest scores for resources allocated to them (lines). These results document a geographical maldistribution of resources related to reproductive health of the sort singled out by Benchmark III in the Guatemalan study (Equitable and sustainable health financing). The Guatemalan team also compared the district scores on the IPPS and IRRHHCo indices. The objective was to assess the appropriateness of specific policy reforms aimed at delivering basic health services in a context of wide inequities. The most important policy reform implemented in the country as part of the health sector reform process is the subcontracting of private providers (not for profit) to deliver a package of basic services to rural population where the network of MoH facilities is insufficient or non-existent 3. This package is based on 26 interventions 4 that include some reproductive health services (antenatal 2 The two indices aim at estimating the need for basic health care services (index of priority) against the allocation of essential resources to deliver those basic services (index of resources). To carry out this estimation, we use tracer indicators of both, health care services and resources. 3 The scheme initiated in More than 120 NGO are contractees of the EBHS scheme. The EBHS have signified a large transfer of Ministry of Health funds to private providers. By the year 2000, more than US$19 million were transferred to contracted providers. 4 A recent study carried out by civil society organizations reports that in many cases, all services included in the package are not delivered, in particular those services with a higher cost ( such as delivery attendance and cancer screening. Among the reasons for the above include insufficient 7

9 care, TT vaccination, folic acid supplementation, delivery and post-natal care, family planning, screening for mammal and cervix cancer). 5 Services are delivered through mobile teams that include medical doctors who make monthly visits to villages. These teams work in collaboration with permanent, communitybased health volunteers and traditional birth attendants. The contracting is based on a capitation payment of US$5.00 per inhabitant. This amount is low. Other countries in the region with similar packages estimate a cost ranging from US$19 up to $US 28 (Bitrán & López 2003). To compensate for a low capitation payment, the strategy in Guatemala is to rely on a large extent in a network of community volunteers. That is why the Guatemalan team developed an index to measure the availability of community volunteers in different health districts. Priority districts enter in the arrangement of receiving financial resources to participate in the subcontracting scheme. To benefit from the scheme, however, priority districts should have a meaningful network of community volunteers. As a way of benchmarking equity in this policy, we compared the scores of high and low priority districts (as measured by the IPSS index) with the district scores on the index of available community worker resources (the IRRHHCo). In Figure 4, San Miguel Chicaj and San Jerónimo y Cubulco are the districts with the highest priority(due to low coverage of basic health services). They also have low scores for the availability of community volunteers in comparison with non-priority districts. These same districts also have low scores for institutional resources (calculated by IR index). Priority districts thus not only suffer inequity in the allocation of institutional resources, but they cannot make up for that inequity by relying on a strong system of community workers to deliver basic services. Priority districts are therefore at a double disadvantage, and current policy reforms are inadequately designed to address the wide inequity experienced by those districts. The adapted framework and the analytical and data collection tools have been disseminated to different institutions within the country. They have generated interest from several organizations interested in equity, especially because they can use secondary data available from the MoH s health information system. As our analysis shows, the kinds of benchmarking we carried out not only highlights specific inequities in the availability of culturally appropriate services, and not only inequities in the allocation of resources to achieve declared goals, but also specific flaws in the design of reform policies. Several organization are now extending the application of the tools to other provinces. 4.2 Ecuador The team in Ecuador built a coalition of different organizations interested in the equity and social justice of health policy. The coalition includes the provincial level of the ministry of health, local government, NGO s and civil society organizations (women s groups and consumers associations). The resources and a lack of effective supervision and monitoring from the MoH to contracted supervisors (INS

10 benchmarks of fairness matrix that was adapted in Ecuador is similar to the one in Guatemala. The Ecuadorian version, however, emphasizes indicators related to maternal health, reproductive health services and child health instead of the more general focus on public health that characterizes the Guatemalan indicators and indices. The most important health policy in Ecuador is the free health care services for mother and children aged under 5. Through this policy, women of reproductive age and children under 5 are treated in public facilities without any cost. The facility is expected to bill the MoH and this in turn will refund the resources used in providing treatment to this age group. Preliminary results from the field application in Ecuador yield some significant findings. For instance, in benchmark II (access to universal care for mothers and children under 5 years) a key criterion is the reduction of financial barriers to care. The benchmarks survey took acute respiratory infection (ARI) as a tracer condition to assess whether services were delivered at no cost. Despite the free health care policy, the assessment found that health facilities in 4 districts (out of 6 surveyed) were charging patients for treatment. The charge varied from US$1 up to US$4. Of even more concern, the district with the largest concentration of population in poverty was the one with the largest percentage (70%) of users of services reporting having paid for health care services included in the free health care law. The above findings were presented to health authorities. Some of the civil society groups participating in the exercise have already requested immediate action from authorities, including a further investigation into the reasons for non-compliance with the free health care policy. Benchmark IV in the Ecuador matrix focuses on improving quality of services for reproductive age women and children, and it includes a criterion concerned with efficiency. To measure change on this dimension, the team took the ratio of medical staff to administrative staff in health facilities (both, public and NGO s) as a proxy indicator of potential inefficiencies in staff distribution. The survey found that on average, public facilities have 7 administrative staff for every 10 medical staff whereas NGO facilities have 3 administrative staff for every 10 medical staff. This suggests that NGO s have a better ratio of medical staff to administrative staff, devoting more of their resources to the direct delivery of care. Public hospitals also showed ratios that range from 1 administrative staff for every 5 medical staff to 1 administrative staff member for every 2 medical. The range suggests considerable inefficiency somewhere. The above information, despite not offering a direct and conclusive measure of inefficiency, does point to an area concern that requires further investigation and action. In fact, provincial authorities from the MoH are interested, as a result of these findings, in pursuing a specific study to clarify staffing issues in public facilities. The two examples above show it is possible to convert monitoring and evaluating using the benchmarks into immediate action aimed at correcting problems. Stimulating such action in the direction of improving equity and social justice or fairness is a key objective of the approach. The Ecuadorian team 9

11 succeeded in this objective by including civil society organizations in the team from the start. 4.3 Implications of work in Ecuador and Guatemala Valuable lessons can be drawn from the experience in both countries. In Guatemala, by developing the adapted matrix and measuring tools (indices) in collaboration with the ministry of health staff, and by using available ministry of health data, the team secured acceptance of and interest in the framework. The ministry of health personnel grasped the inequities revealed by the analysis of routine data, and they wanted to understand further the factors involved and uncover ways to improve the situation. In Ecuador, a key lesson is the importance of involving civic society organizations in the assessment exercise. Participating consumer groups were alarmed by some of the findings, particularly the noncompliance with the free health care services law, and they requested actions be taken to address the issue. The participation of civic society groups ensures that findings do not become solely an academic exercise and that evidence of unfair practices can be used to move the system toward improvements in equity and the fair delivery of reproductive and other health care services. Teams in both countries used methods at the local level to monitor inequities. They mostly used routine information that is often available locally but under-utilized in developing countries. This approach can be generalized to many settings. 4.3 Cervical Cancer Screening Program in Mexico The Ecuador and Guatemala uses of the benchmarking approach focused on reproductive health more generally. In contrast, the Mexican adaptation of the benchmarks concentrates on a specific reproductive health issue, cervical cancer, though the approach can be generalized. Evaluating the equity and fairness implications of the Mexican Cervical Cancer Screening Program (CCSP) is particularly important because the program targets a traditionally marginalized population group and also because the program is focuses to on preventive actions that have traditionally been given a lower priority than curative interventions. Equity is involved in two ways: it is women who are dying unnecessarily from a preventable condition, and some groups of women are doing better than others in Mexico. The Cervical Cancer Screening Program carried out in Mexico between 1995 and 2000 includes as its main activity the periodic screening of women at risk. It is a free program available in every public health care facility. However, cervical cancer mortality fell only slightly between 1995 and 2000, from 21.6 to 19.2 per 100,000 women aged 25 years or more. Recent studies suggest different factors that explain the program limitations, many of them related to an unfair and inequitable program. For that reason it was pertinent to review and organize all the evidence according to their equity and fairness implications to suggest some explanations. The Benchmarks of Fairness constitute a useful tool for the analysis and organization of that evidence. But that requires adapting the 10

12 Benchmarks for this purpose and then using the adaptation to evaluate implementation of the cervical cancer screening program Steps in the application of the benchmarks to cervical cancer screening With these two objectives in mind, we focused on secondary and tertiary information generated by the government and several academic and nongovernmental organizations. These included official documents, grey (unpublished) literature, academic books, journal articles, and working papers. The analysis of information was done through content analysis. Through this analysis we determined which actions and previous research findings were related to fairness and equity issues and in particular to those benchmarks and corresponding criteria relevant to cervical cancer screening (Table 6). The result is an analytical framework that allows us to organize, according to their contribution to equity and fairness, all the actions and outcomes of the CCSP. For each criterion one or more indicators were selected that allow us to monitor the performance of the program in relation to the benchmarks and corresponding criteria. Indicators are not an infallible measure; there are aspects of each criterion that remain unmeasured by the available data. For that reason, the description of the actions carried out as part of the program is extremely useful since it provides information on program performance. The indicators selected are feasible to obtain and most of them are already being generated by the health system. Even when the specific value of several of those indicators was not available for the years 1995 and 2000 they are now. The rest of the indicators can be obtained through an exit survey to program users applied in two moments of time. Table 7 presents a sample of criteria, indicators and information sources Rationale for Specific features of the Benchmarks adaptation In a fair and equitable screening program, all women should have access to an opportune Pap smear regardless of their income. The availability and characteristics of the CCSP should contribute to reducing the opportunity cost of using the program [Benchmark1] (Daniels 1996) (Doyal 2000) (Gomez 2000) (Braveman 2003). It is also expected that human resources, infrastructure and information will be adequate and sufficient to assure the access to the program of every women at risk, and that health care providers and decision-makers will consider practices and beliefs relevant to disease and health in the design and implementation of the program in order to facilitate its use by women from different cultures [Benchmark 2] (Whitehead 1992) (Daniels et al 1996). All women at risk should be covered by the program with equal benefits regardless of class or geographic location [Benchmark 3] (Braveman and Gruskin 2003) (Daniels et al 2000). To guarantee the access and effectiveness of the program requires an appropriate level of technical and operational quality: low quality of care will be a disincentive for women to attend or continue the program and low quality of the screening process will reduce the sensibility and reproducibility of 11

13 the screening procedure [Benchmark 4]. In a fair program is expected to have accountability processes intended to improve health service delivery in general and in particular make them more responsive to reproductive health for marginalized groups [Benchmark 5] (Daniels et al 1996) (George 2003) Application of existing data to benchmarking the CCSP All women have the option of receiving a Pap smear free of charge. In this sense, financial contribution is equitable among women. However, those women who obtain a Pap smear without paying a user fee have to deal with long waiting lists and low quality smears (Lazcano-Ponce etal 1999) (Gomez-Jauregui 2001). The expenditures on reproductive health in Mexico decreased by 33% between 1993 and 1996, although, in that same time period education expenditures increased by 30% and national security expenditures increased by 57% [Benchmark 1] (Espinosa and Paredes 2000: 75-79). There was an increase in the infrastructure and skilled human resources used in the cervical cancer screening program between 1996 and However, this infrastructure was sufficient to screen the targeted women only once every 5 years [Benchmark 2] (Lazcano 1996) (Sankaranarayanan et al 2001). According to the Cervical Cancer official norms, public health care providers are responsible for giving information on the risk of cervical cancer and on methods of prevention to all women at risk. However, there is no mechanism to monitor these actions. Evidence has shown that information is not provided on a regular and equitable basis. Women living in rural areas and women with less education have less access to information [Benchmark 2] (Lazcano-Ponce et al 1999) (Lazcano et al 2002) (Aguilar-Perez 2003) (Najera P 1996). There are also cultural behaviors and beliefs that limit the access to the cervical cancer smears. The National Cervical Cancer Screening Program has not taking into account the unwillingness of women to have a pelvic exam that may be embarrassing or painful, or the disapproval of the male partner [Benchmark 2] (Lazcano-Ponce et al 1999) (Aguilar-Perez 2003) (Watkins et al 2000). Despite the resources allocated to the CCSP, and the personnel and health care facilities involved in it, the national coverage of women at risk is still very low. Only 43.2 % of the target population in 1994 (one third of women of 25 years old and more) and 57.8% in 2000 are covered (Ministry of Health 2001b). Women living in rural areas, who are less educated and in the poorest locations have less access to information, are less likely to have a Pap smear, and have a higher probability of dying of this cause [Benchmark 3] (Meneses-Gonzalez etal 1999) (Palacio-Mejia 2003) (Lazcano-Ponce et al 1999) (UNFPA 2003)(Lazcano- Ponce et al 2002) (Torres-Mejia etal 2002). There are frequent reports about inadequately sensitive care provision and a lack privacy in the public sector when these providers perform the Pap smear. (Espinosa and Paredes 2000) (Lazcano-Ponce et al 1999). Between 12

14 1996 and 1998 an intensive training program was provided for personnel in the screening program. Nevertheless, studies show that health care personnel lack knowledge about cervical cancer risk factors and treatment (Arillo-Santillan et al 2000). Several studies have shown a low diagnostic performance in public cytology laboratories belonging to the Ministry of Health and emphasized the need for continuing education and establishment of quality control mechanisms (Weissbrod etal 1994, 1996). (Lazcano etal 1997 a). (Lazcano 1996) (Alonso de Ruiz et al 1996) [Benchmark 4]. An important problem with the surveillance system in Mexico is the inaccuracy of information. The information regarding the performance of the program has been limited (Palacio-Mejia 2003). Regarding fair grievance procedures, in 1996 the MoH created the National Commission for Medical Arbitrage (CONAMED), whose main objective is to help resolve controversies among users and providers of health services through simpler procedures than legal complaints. Between 1996 and % of the complaints related to oncology services received were related to screening and treatment of ovary and cervix malignant tumors (Jimenez-Corona ME et al 2002) [Benchmark 5]. In summary, despite the apparent interest of the government in cervical cancer, the resources for the CCSP were very limited. The women dying were mostly poor, uninsured, less educated and from rural areas. Cervical cancer mortality is unacceptable since the current scientific and technical knowledge allows the early detection and effective treatment of cervical cancer. The actions intended to address this issue through the CCSP are inadequate and unfair because the socioeconomic status and location of women affect their possibility of having a Pap smear in time to prevent them from dying of cervical cancer Some conclusions regarding the Mexican application The benchmarks of fairness are a useful tool for systematically organizing existing evidence about the performance of an ongoing reproductive health program and using that evidence to make integrated judgments about the contribution of the program s actions to equity and fairness. The purpose of organizing this evidence base is to promote discussion among decision makers and researchers about the fairness and equity implications of a policy process (Daniels et al 2000). In this case, the analysis showed the positive and negative effects on fairness and equity of the actions carried out by the CCSP. In order to effectively reduce cervical cancer mortality the program currently implemented should pay attention to the failures and successes of the CCSP in achieving each of the five benchmarks and the reasons behind those achievements. We now plan to systematize the use of the benchmark matrix and related indicators to assess the CCSP program in the period after We believe this analytical framework is also useful for analyzing the equity and fairness implications of cervical cancer screening programs in other countries. This work represents a first step in the application of the benchmarks of fairness to other aspects of reproductive health. 13

15 5 Some more general conclusions The following points emerge from these cases: 1. The benchmarking approach can employ existing data from previous studies and integrate them into an ethically coherent framework for assessing equity and fairness more generally. This use, illustrated in the Mexican case, depends on others providing studies of relevant aspects of the benchmark criteria. 2. The benchmarking approach can develop specific indicators and indices to monitor and evaluate performance using available information sources (Guatemala and Mexico). When this approach is combined with involving ministry of health personnel in the process, they take interest in the results and are motivated to apply them (Guatemala). When this approach also involves civic society groups (Ecuador), the chance of converting monitoring into action is enhanced. 3. In some countries, locally accessible information of the sort used in Guatemala and Ecuador is not available. There may also not be studies of the sort drawn on in the Mexican case. In these settings the teams applying the benchmarking approach must select criteria and construct indicators for ongoing monitoring and evaluation that use what information is available. We have not illustrated this approach but variations on it have been developed in some African sites where information systems are less developed. Report of such experiences can be accessed through the benchmarks website 14

16 References Aguilar-Perez J, Leyva-Lopez A, Angulo Najera D, Salinas A, Lazcano-Ponce E (2003) Tamizaje en cáncer cervical: conocimiento de la utilidad y uso de citología cervical en Mexico. Rev Saude Pública. 37(1): Alonso de Ruiz P, Lazcano-Ponce E, Duarte-Torres R, Ruiz-Juarez I, Martinez- Cortez I (1996) Diagnostic Reproducibility of Pap Testing in two regions of Mexico: the need for quality Control Mechanisms. Bull Pan Am Health Organ 30(4): Arillo-Santillan E, Lazcano-Ponce E, Peris M; Salazar-Martinez E; Salieron- Castro J; Alonso-De Ruiz P (2000) El conocimiento de profesionales de la salud sobre la prevención del cancer cervical. Alternativas de educación medica. Salud Publica Mex 42: Bitrán R & López A (2003). Asignación presupuestaria al MSPAS de Guatemala. Proyecto PHRplus Guatemala. Powerpoint presentation. Braveman P (2003) Monitoring Equity in Health and Healthcare: a conceptual framework. J Health Popul Nutr. Sep. 21(3): Braveman P, Gruskin S (2003) Defining equity in health. J Epidemiol Community Health. 57: Daniels N, Flores W (2004) An Evidence-Based Approach to Benchmarking Fairness in Health Sector Reform in Latin America Unpublished manuscript Daniels,N, Bryant J, Castano RA, Dantes OG, Khan KS, Pannarunothai S (2000). Benchmarks of fairness for health care reform: a policy tool for developing countries. Bulletin of the World Health Organization 78(6): Daniels N (1998) Ethics and health care reforms: a global view. In Bankowski Z, Bryant JH, Gallagher J, editors. Ethics, equity and health care for all. Geneva: CIOMS;pp Daniels N, Light DW, Caplan RL (1996). Benchmarks of fairness for health care reform. New York: Oxford University Press. Daniels N, Brock D (1994). Ethical foundations of the Clinton Administration's proposed health care system. Journal of the American Medical Association 271: Daniels N (1985) Just Health Care New York: Cambridge University Press. 15

17 Doyal, L (2000) Gender equity in health: debates and dilemmas. Social Science & Medicine 51: Espinoza, G. Paredes, L (2000) Salud Reproductiva en México. Los programas los procesos, los recursos financieros. En Espinoza G. (ed.) Compromisos y Realidades de la Salud Reproductiva en México. El Atajo Ed. / UAM. George, A (2003) Using accountability to improve reproductive health care. Reproductive Health Matters. 11(21): Gomez E (2000). Equity, gender and health policy reform in Latin America and the Caribbean. PAHO. Gomez-Jauregui J (2001). Costos y calidad de la prueba de detección oportuna del cáncer cervicouterino en una clínica pública y en una organización no gubernamental. Salud Publica Mex 43: INS (2003) Monitoreo del Derecho a la Salud en el Marco de la Reforma del Sector Salud en Guatemala. Instancia Nacional de Salud. Jiménez-Corona ME, Rivera-Cisneros AE, Barrera-Romero N, Manuell-Lee GR, De la Garza JG, Torres-Lobaton A, Tena-Tamayo C (2002). Recomendaciones para mejorar la practica de la medicina en la atención del paciente con cancer. Revista CONAMED11(22): Lazcano E, Nájera P. Alonso P, Buiatti E, Hernández M (1996). Programa de Detección Oportuna de Cáncer Cérvico-Uterino en México. Diagnóstico situacional. Rev Inst Nac Cancerol; 24(3): Lazcano-Ponce EC, Moss S, Alonso de Ruiz P, Salieron-Castro J, Hernandez-Avila (1999). Cervical cancer screening in developing countries: Why is it ineffective? The case of Mexico. Archives of Medical Research, 30: Lazcano-Ponce, Alonso de Ruiz P, Lopez-Carrillo L, Najera-Aguilar P, Avila-Ceniceros R, Escandon-Romero C, Cisneros MT, Hernandez-Avila M (1997). Validity and reproducibility of cytologic diagnosis in a sample of cervical cancer screening centers in Mexico. Acta Cytologica, 41: Lazcano-Ponce, Moss S, Cruz-Valdez A et al (2002). The Positive Experience of screening quality among users of a cervical cancer detection center. Archives of Medical Research 33: Meneses-Gonzalez F, Lazcano-Ponce E, Lino-Gonzalez M, Hernandez M, Lezana MA, Najera P, Sepulveda J (1999). Prevalencia de uso de la prueba de papanicolaou en mujeres de 15 a 49 años en Mexico. Cancerologia. 45(1) Ministry of Health (1998). Diario Oficial. Modificación a la Norma Oficial Mexicana NOM-014- SSA para la prevención, control y tratamiento del cáncer de cuello del útero. México, D.F., 6 marzo. Ministry of Health (2001b). Programa de Accion: Cancer Cervicouterino. Subsecretaria de Prevencion y Proteccion de la Salud 16

18 Najera P, Lazcano-Ponce E, Alonso P, Ramírez T, Cantoral L, Hernández M (1996) Factores asociados con la familiaridad de mujeres mexicanas con la función del Papanicolaou. Bol Oficina Sanit Panam 121(6): Palacio-Mejia L, Rancel-Gomez G, Hernandez-Avila M, Lazcano-Ponce E (2003). Cervical cancer, a disease of poverty: mortality differences between urban and rural areas in Mexico. Salud Publica Mex. 45 Supl. 3: S315-S325. Sankaranarayanan R, Madhukar A, Rajkumar R (2001). Effective Screening programmes for cervical cancer in low- and middle-income developing countries. Bulletin of the World Health Organization. 79(10): Torres-Mejia G, Salmeron-Castro J, Tellez-Rojo M, Lazcano-Ponce E, Juarez- Marquez S, Torres-Torija I, Gil-Abadie L (2002). Characteristics of respondents to a cervical cancer screening program in a developing country. Archives of Medical Research 33: UNFPA (2003). Improving the Quality of Reproductive Health Care. accessed 15/02/04 Watkins M, Cabali C, Winkleby M, GaonaE, Lebaron S (2002). Barriers to cervical cancer screening in rural Mexico. Int J Gynecol Cancer 12: Weissbrod D, Torres M, Rodríguez A, Ureña I, Estrada J, Reyes ML (1996) Comparación del examen de citología cervical efectuado por el método Papnet y por microscopía convencional. Bol Oficina Sanit Panam 121: Whitehead M (1992). The concepts and principles of equity and health. Copenhague: WHO Regional Office. 17

19 Table 1: Nine benchmarks and corresponding concerns of fairness Benchmark Concern of Fairness B1 Intersectoral Public Health B2 Financial Barriers to Equitable Access B3 Nonfinancial Barriers to Access EQUITY B4: Comprehensiveness of Benefits and Tiering B5 Equitable Financing B6 Efficacy, Efficiency, and Quality Improvement EFFICIENCY B7 Administrative Efficiency B8 Democratic Accountability and Empowerment ACCOUNTABILITY B9 Patient and Provider Autonomy 18

20 Table 2. Distribution of women and language skills among health personnel PERSONNEL TOTAL WOMEN SPEAK LOCAL LANGUAGE Doctors Nurses Auxiliary Nurses Rural health technicians Institutional facilitators Community facilitators Figure 1. Deliveries by different providers. Baja Verapaz region, DELIVERIES BY DIFFERENT PROVIDERS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% SALAMA SAN MIGUEL CHICAJ RABINAL SAN JERONIMO PURULHA EL CHOL GRANADOS CUBULCO NONE FRIEND/RELATIVE TBA DOCTOR 19

21 Table 3. Index of priority for health services (IPSS) IPSS= (Ciin-CDxin ) + (Ciap-CDxap ) + (Cips-CDxps ) = Va Ciin Ciap Cips 3 IPSS= Index of priority for health services Ciin= Ideal coverage for immunization (100%) CDxin= Immunization coverage for district X Ciap= Ideal coverage for antenatal care (100%) CDxap= Antenatal coverage for district X Cipss=Ideal coverage for supervised deliveries (100%) CDxps=Coverage of supervised deliveries for district X Va= Sum of three values Table 4. Index of resources (IR) IR = (GPDx X 0.4 ) + (MDx X 0.3)+ (FDa X 0.3) GPDa MDa FDx IR= Index of resources GPDx= per capita expenditure district x GPDa= District with the highest per capita expenditure MDx= Medical staff per population for district x MDa= District with the highest number of medical staff/pop FDa= District with the highest number of health facilities per population FDx= health facility per population in district x Table 5. Index of availability of community volunteers (IRRHHCo) IRRHHCo = (PrDx X 0.33 ) + (CoDx X 0.33)+ (CosDx X 0.33) PrDa CoDa CosDa IRRHHCo= Índex of availability of community volunteers Prx= Health promoters per 1,000 inhabitants in district x PrDa= District with highest number of health promoters per population CoDx=Traditional birth attendants (TBA) per 10,000 inhabitants in district x CoDa= District with the highest number of TBA s per population CosDx= % of communities within x district organizad in health committees CosDa= District with the highest % of communities organized in health committees. 20

22 Figure 2: Index of Priority for Health Services (IPHS) vs. Index of Resource Distribution (IRD) in districts of Baja Verapaz region. Vertical Bars are measures of priority, the higher the value, the greater the need for resources to fill gap in coverage; the points represent the index of resource distribution, with higher values corresponding to greater allocation per district. The mismatch is a reflection of inequity in meeting needs. IPHS VERSUS IRD COEFICIENT IPSS IR SAN MIGUEL CHICAJ CUBULCO GRANADOS SAN JERONIMO PURULHA EL CHOL RABINAL SALAMA 21

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