latin america and caribbean | iDSI

Quality Indicators in Mexico

Global Health and Development — Wed, 30 Mar 2016 14:52:40 +0000

About the project

Between 2001 and 2006, a national set of quality indicators known as INDICAS (Sistema Nacional de Indicadores de Calidad en Salud) were developed by the Mexican government. The government has implemented many initiatives on the use of quality indicators and their role in performance monitoring. A key aim of the governments initiatives is to support the use of INDICAS within institutions in Mexico responsible for the provision of health care.

The General Directorate of Quality and Health Education (Dirección General de Calidad y Educación en Salud – DGCES) began a project on the “Evaluation, Design and Implementation of the National System for Quality Care Monitoring”. The project had support from the Inter-American Development Bank. After invitation, NICE International successfully submitted a proposal to provide technical support on the project.

The NICE International work programme aims to support the DGCES in strengthening the existing monitoring system. The programme focuses on the development of a sustainable and robust methodology for indicator development. It builds on the existing strengths of key stakeholder organisations in this area.

NICE International release report from situational analysis in Mexico

March 2016

NICE International and Prof. Stephen Campbell (University of Manchester) released a Situational Analysis report summarising lessons and recommendations from the early part of the IADB-funded Quality Indicators project. The report details current obstacles in the Mexican health system which have hindered the development of a sustainable and robust methodology for using indicators. Some challenges relate to the Mexican health system being fragmented across separate public insurers, which have provided healthcare, defined quality, and managed health facilities in parallel to one another. Private healthcare providers are also predominant and effectively work independently. However, even when the main institutions in the health system work together and submit data at a national level, these activities are largely not coordinated. For example, while epidemiological data, clinical guidelines, data systems and indicators all exist, there is no coherent system for integrating these.

Read the situational analysis report

Interviews and discussions emphasised that despite excellent capacity and data which can potentially be used for quality improvement, this is hindered by the particular fragmentation of the Mexican healthcare system. There are key elements missing or a lack of integration at present that prevent coherent quality improvement in health care and lead to duplication and waste of resources and data. It is not known how far indicator sets developed by different public institutions overlap, making comparison across different sub-systems impossible in most cases. There is also no national system for using quality indicators to track quality of care and give feedback to providers, particularly due to the lack of electronic health records and unique patient data. For these reasons, many of the recommendations in this report focus on improving coordination between the main institutions.

The report details a set of phased recommendations to the Ministry of Health/Government of Mexico over the next five years, which were discussed in an earlier form with stakeholders in December 2015. The immediate, medium- and long-term recommendations cover five mutually reinforcing areas:

political will and policy
prioritisation of topics for indicator development
commitments and investment to introduce a unique patient identifier
communication and monitoring of a core national indicator set
data collection and analysis on core indicator set

This report was agreed by Mexico’s Ministry of Health to be a publicly available resource. It was submitted by NICE International in January 2016, and was finalised and disseminated following a consultation period with the main institutions NICE met during previous visits.

NICE International visit Mexico with academic partner for Quality Indicator project

November 2015

At the end of November 2015, NICE International team members visited Mexico City with Professor Stephen Campbell (University of Manchester), the academic partner on the IDB-funded Quality Indicator project. The purpose of the trip was to present key recommendations from a draft situational analysis report and to discuss the capabilities and institutional arrangements for using quality indicators, following on from the initial visit in September 2015. The final report recommendations will tie into the Total Quality Model (Modelo de Gestión de Calidad) developed by the Ministry of Health.

Prof. Campbell, Francis Ruiz and Laura Morris attended meetings with the DGCES (the department of Mexico’s Ministry of Health leading on the quality project) and representatives from the following Mexican agencies:

Instituto Mexicano del Seguro Social (IMSS)
Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE)
Comision Nacional de Proteccion Social en Salud (CNPSS/Seguro Popular)
Centro Nacional de Excelencia Tecnologica en Salud (CENETEC)
Consejo General de Salud (CGS) (inter-agency body)
Comité Nacional por la Calidad en Salud (inter-agency body)

Key themes identified during the discussions included the need for organisational coordination, the need for Unique Patient Identifiers (and previous unsuccessful attempts to introduce these in Mexico) and the need for the processes for indicator development to include a nationally relevant prioritisation method.

During the visit, the team also attended a meeting of the inter-agency National Committee for Health Care Quality and delivered an interactive workshop for policy-makers and technicians about the development and use of quality indicators. This workshop focussed on core principles of quality measurement and the development, testing and implementation of indicators, with reference to international literature and case studies. Examples of successful and relevant indicator schemes included the UK Quality and Outcomes Framework (QOF) and the Thai QOF.

NICE International sees DGCES as a key coordinating body in the development and dissemination of a core set of national indicators that can be used across organisations in Mexico, most of whom are currently developing and using quality indicators separately to one another. The General Directorate of Health Information (DGIS) is also a key Ministry partner gathering and using health and healthcare performance data to inform these indicators, along with CENETEC, CGS and other agencies.

In 2016, NICE International and Prof. Campbell will lead on a unified Methods and Process Manual for indicator development in Mexico. The early phase of this project will continue until summer 2016 and NICE International expects to participate again in the Mexican Quality Forum.

Mexican quality forum

October 2015

The Director of NICE International visited Mexico City at the invitation of the Ministry of Health (MOH) for the annual Quality Forum held over 3 days and attended by just under 3,000 people from across Mexico as well as numerous countries in South America, the USA and Europe and representatives of WHO, PAHO and OECD.

Kalipso Chalkidou gave a plenary on quality standards and their application across the English NHS with a focus on diabetes management. At the fringes of the meeting, Kalipso held meetings with NICE International’s partners at the MOH, the Quality and Education Directorate, to discuss progress with the IADB-funded quality improvement work and also with CENETEC to explore potential opportunities for partnering up in sharing experiences with technology assessment. The discussions were chaired by the undersecretary, Dr Eduardo González Pier and attended by Dr Sebastián García Saisó, as well as Healthcare UK representation, amongst others.

It was agreed that NICE International will continue to work with the Mexican MOH especially under the bilateral UK/Mexico MOU which identifies HTA and quality as key priority areas. We look forward to welcoming the Mexican Minister and her team to London in March 2016.

NICE International begins a situational analysis as part of Mexico Quality Indicator project

September 2015

NICE International and Prof. Stephen Campbell (University of Manchester) travelled to Mexico to review the current capabilities for developing and implementing quality indicators.

They held talks with representatives from the following key Mexican stakeholders:

Instituto Mexicano del Seguro Social (IMSS)
Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE)
Seguro Popular
Directorate General of Information
and DGCES.

The talks highlighted key points to ensure the sustainability and local ownership of effective quality indicators including:

The need for more collaboration among public sector stakeholders to encourage data sharing.
The development of evidence-informed guidance to support the creation of indicators.

Healthcare Priority Setting in the Courts: Introducing a Working Paper

Global Health and Development — Mon, 01 Feb 2016 16:10:39 +0000

The judicialization of the right to health plays a significant role in the success of priority setting for universal health coverage. The right to health is entrenched in international treaties signed by all UN member states, and the constitutional and legislative law of over 50% of countries. And, patients are increasingly turning to the courts to uphold this basic human right to health. In certain instances, individuals utilize the judicial system to access their right to health in a well-founded fight for the drugs their health system has promised to provide but failed to do so. In others, citizens argue against the unfair processes used to determine who will get what care. These valiant efforts and just causes represent only a few of the positive ways in which patients have “judicialized” the right to health.

However, as with most things, the judicialization of the right to health is not without problems, creation of difficulties, or imposition of setbacks. In certain instances, patients are taking to the courts to argue that the government’s (or, one of its subsidiary’s) failure to provide physician-prescribed care is against their right to health—even when that decision not to provide coverage was due to intentional priority setting. Of course, sometimes priority setting is conducting improperly, ambiguously, or unfairly, and the court’s involvement could be critical. However, where the courts overturn explicit, transparent priority setting decisions, they could threaten the stability and effectiveness of priority setting institutions or the prioritization recommendations themselves.

This working paper, Healthcare Priority Setting in the Courts, offers an in-depth look at over twenty court opinions across Latin America, Africa, and Europe grappling with whether prioritization has compromised an individual’s right to health. In some cases, the decisions explore whether the priority setting decision itself has threatened a person’s right to health—in others, whether the priority setting process itself is unfair. Where applicable, the review of each case offers insight into why the court decided the way that it did, and what international or national laws the court felt the priority setting decision did or did not contradict. Where relevant, the decisions are framed against the context of the country’s legal system and general experiences managing the judicialization of the right to health. Even more broadly, the paper considers how the judicialization of the right to health may differ within civil law legal systems (such as Brazil and Argentina), or common law legal systems (such as England or Israel).

Needless to say, all legal systems are different, and courts are not required to follow prior decisions (as is especially true in civil law systems). Yet, it is our hope that insight into the specific reasoning behind these decisions will help government, priority setting institutions, and policy makers understand how and why the courts decide in order to prepare for and anticipate cases in the future. The paper concludes with a discussion on how governments could aim to support explicit, transparent, and equitable priority setting processes in hopes of striking a new balance between priority setting and the critical role that the courts should continue to play ensuring and upholding the rationality and fairness of priority setting. This latter idea is explored in-depth in the recent publication: The International Right to Health: What Does it Mean in Legal Practice and How Can it Affect Priority Setting for Universal Health Coverage? as part of Health Systems & Reform Journal’s Special Issue for the 2016 Prince Mahidol Award Conference.

As the work continues to grow, we invite and encourage your thoughts, feedback, and recommendations.

Rebecca Dittrich is a Juris Doctorate Candidate at the Georgetown University Law Center and a Master of Public Health Candidate at the Johns Hopkins Bloomberg School of Public Health. She is a NICE International Associate.

179 LMICs, 1 iDSI: Where do we start? Setting priorities in international development

Global Health and Development — Fri, 29 May 2015 09:16:51 +0000

Priority-setting is important for all countries, regardless of level of economic development, if the goal is to achieve and sustain universal health coverage (UHC). One year ago in Geneva, the World Health Assembly endorsed a resolution on Health Intervention and Technology Assessment (HITA), calling on member countries to support each other in strengthening institutional and technical capacity for priority-setting. The question for iDSI and our funders was, with 179 low- and middle-income countries (LMICs) in the world: where should we start? How would we decide where our practical support would generate the greatest impact, in helping countries achieve better decisions for better health? To answer these questions, the Office of Health Economics in conjunction with NICE International has published a report mapping out the priority-setting landscape in 17 LMICs across Asia, Africa and Latin America.

We needed to know who were making priority-setting decisions in the respective health systems, how these decisions were being made and financed, what technical capacity countries had to implement HTA processes, as well as the key challenges facing their health systems. But at the time, there was no comprehensive literature covering all of these issues of relevance to priority-setting, within a broad enough geographical scope. Existing surveys on HTA (including those done by NICE International and HITAP) tended to focus narrow on its technical aspects, whereas studies from the health systems research field didn’t go deep enough into the important facets of priority-setting such as who are the stakeholders, what evidence is used, and so on.

With the end goal of selecting a country to offer iDSI practical support that would be feasible, in demand, and generate significant impact, we set out to assess how ready countries were for priority-setting support. We developed a conceptual framework, methods (including a country selection process), qualitative and quantitative indicators, and data collection tools (including questionnaires and interview guides) for priority-setting readiness. The mapping combined published and grey literature, insights from iDSI partners, and primary data collection from in-country key opinion leaders. And thanks to the hard work of iDSI partners worldwide, we successfully completed mapping of 17 countries within the space of 7 months.

Since completing the mapping, we have used it to select Indonesia as our focal country partner, where HITAP, NICE International and PATH are working in collaboration with local decision makers and academics to support HTA development. We have also subsequently secured additional funding to support a Sub-Saharan African regional hub for priority-setting around PRICELESS SA, South Africa.

One year on from the HITA resolution, there has been a proliferation of regional mapping exercises for priority-setting capacity, coinciding with the global momentum to support HITA. These include WHO-led efforts as well as iDSI partnerships with WHO regional initiatives (such as the Asia Pacific Observatory on Health Systems and Policies, and Advance HTA with PAHO). As the global health and political scene is so fast moving, some of the findings in the iDSI mapping report are inevitably already out of date. My hope is that these latest efforts will add to our global knowledge and provide practical insights to international donors and development partners, in order to support country partners in building capacity for better priority-setting in health.

Mapping of priority-setting in health in 17 low and middle income countries across Asia, Latin America, and Africa

Global Health and Development — Wed, 20 May 2015 10:57:20 +0000

A new OHE occasional paper has just been published, written in collaboration with NICE International. The document aims to assess the characteristics of a sample of low and middle income countries (LMICs), in order to select a shortlist of countries in which an iDSI practical support project could have the maximum likelihood of success and possible impact. The practical support project would assist one country in building institutional and technical capacity in priority-setting for universal health coverage (UHC).

We identified a longlist of 17 LMICs across three regions, with a broad mix of geographical representation, population size and economic performance: Brazil, Chile, Colombia, Mexico, Uruguay, Ghana, Kenya, Malawi, South Africa, Uganda, China, India, Indonesia, Myanmar, Philippines, Thailand and Vietnam. In order to assess priority-setting readiness in each country, we developed qualitative and quantitative indicators covering: political will, current position along the UHC journey, institutional and technical capacity, health system financing characteristics, and potential economies of scale in priority-setting. We gathered and synthesised data up to May 2014 on countries’ priority-setting readiness from various sources, including literature review, key opinion leader questionnaires and in-depth interviews.

In shortlisting candidate countries for iDSI practical support, we excluded: (1) countries that have already established a dedicated, centralised priority-setting institution), (2) countries that have not articulated a political commitment to priority-setting for UHC, and (3) countries where iDSI partners may be limited in their ability to gain traction.

We applied our exclusion criteria and identified a shortlist of four countries: Indonesia, Myanmar, South Africa and Ghana. All four shortlisted countries shared a common vision of increased public financing and provision of healthcare, with explicit priority-setting recognised as a crucial means of ensuring sustainable UHC. Leaders in all four countries have expressed a strong interest in working with iDSI in their effort to introduce UHC. In any of the four countries, an iDSI practical support project would likely to be feasible, and generate economies of scale within and across regions. iDSI could support institutional and technical capacity building for priority-setting and add significant value for each of these countries in different ways that are aligned with the strategic priorities of iDSI funders Bill & Melinda Gates Foundation and UK Department for International Development (DFID), and of high-level decision makers in those countries.

Download the full paper here.

Following the completion of this paper and a scoping visit in July 2014, Indonesia was selected by iDSI as the partner country for an ongoing practical support project to support HTA development.

For more information contact Karla Hernandez-Villafuerte at OHE.

– See more at: https://www.ohe.org/news/international-decision-support-initiative-idsi-mapping-priority-setting-health-17-low-and#sthash.lz3LaQkb.dpuf