Benchmarks of Fairness in

Health Care.
A framework of analysis
Health, Ethics, Equity, & Rights. 2009.
Kausar S Khan
This presentation includes some slides from Norman
Daniel’s presentation in Bangladesh.

Kausar S Khan. CHS/AKU HEER March 3

2009 1
Benchmarks of Fairness
Session Outline

# Sessions
1 Defining fairness in health
a) Complete the sentence: By Fairness in health I
mean ….
2 Presentations
BM (Norman Daniels)

Kausar S Khan. CHS/AKU HEER March 3 2009 2

 Terms By Fairness I mean …..
discussed (Student response)
1. Nobody is deprived of health care they need
2. Everyone has equal opportunity for better health.
3. Everyone has equal access for better health.
4. To bring uniformity in health parameters
5. Distribution of health on the basis of equity.
6. Meeting health needs
7. Allocation according to needs
8. Justifiable decision making – through efficiency,
accountability and equity.

Kausar S Khan. CHS/AKU HEER March 3 2009 3

Benchmarks of Fairness

Fairness is a multi-dimensional concept,

broader than the concept of equity .

Kausar S Khan. CHS/AKU HEER March 3 2009 4

 o f
r k s
m a es s
n c h i r n
Be Fa
l e s o rs
n ts r i ab ca t
me V a n d i
E l e 2 . 3 . I
1.

Kausar S Khan. CHS/AKU HEER March 3 2009 5

Benchmarks of Fairness
Goal, Criteria and Indicators
Three
i n e Goals
N
r ks
ch ma Governance

Be n
Equity Efficiency
3 BM

5 BM 1 BM
h B M has
Eac
b le s; Each
Varia
a r ia b le has
V
d i ca tors
in

Kausar S Khan. CHS/AKU HEER March 3 2009 6

Goal, Criteria and Indicators

Goal
a l
go
e
s ve : t h
l e
b hie
r i a or s
a oa c c t a
a / V t a
f eri
i
er eded t e
h crit al.
i t g e
Cr ne zin h
li e t the g o
r s s
r ion iev ga
c to t o t ch hin
Fa di c a r a
e o a ac
n
I or o p t r re
d
f
e de d fo
ne tifie
e n
id

Kausar S Khan. CHS/AKU HEER March 3 2009 7

Equity – Benchmarks 1 - 5

BM 1 -- Inter-sectoral Public Health.

BM 2 -- Financial Barriers to Equitable Access
BM 3 -- Non-Financial Barriers to Access
BM 4 -- Comprehensiveness of Benefits and
Tiering
BM 5 -- Equitable Financing.

Kausar S Khan. CHS/AKU HEER March 3 2009 8

Example Equity.
Benchmark 2, its variables, & indicators

Benchmarks 2: Financial Barrier to Equitable Access

2.1 Non-formal Sector Coverage

2.1.1 Proportion of population with full health coverage provider
2.1.2 % of families that borrow money for health care
2.1.3 # of families that flip in to deeper poverty due to
disease
2.2 Formal Sector Coverage
2.2.1 % of facilities where unofficial extra charges are demanded
2.2.2 %of facilities authorized to charge for drugs etc
2.2.3 % of facility with active patient welfare society whether
all facilities legally authorized emergency care (capacity)

Kausar S Khan. CHS/AKU HEER March 3 2009 9

Efficiency * -- Benchmarks 6
Variables
Efficacy – it is effective,
Efficiency -- it is evidence based
Quality of care.
*A system that gets more value for money in the
use of its resources is fairer to those in
need…Efficiency should not be seen as an
enemy of equity. N.Daniel et al.

Kausar S Khan. CHS/AKU HEER March 3 2009 10

Governance – Benchmarks 7, 8, 9

BM 7 Administrative Efficiency
BN 8 Democratic accountability and
empowerment
BM 9 Patient and provider autonomy

Kausar S Khan. CHS/AKU HEER March 3 2009 11

Example Governance.
Benchmark 7 , its variables, & indicators

Benchmarks 7: Administrative Efficiency

7.1Minimize administrative overhead

7.1.1 Inappropriate equipment acquisition
7.1.2 Inappropriate equipment allocation
7.1.3 Appropriate provision of providers per population
7.2Minimize abuse, fraud and inappropriate incentives
7.2.1 % of shadow providers in a district
7.2.2 % of public sector practitioner auto-referral
7.2.3 Proportion of un-credentialed practitioners in
district

Kausar S Khan. CHS/AKU HEER March 3 2009 12

Example Governance.
Benchmark 8 , its variables, & indicators

Benchmark 8: Democratic Accountability and

Empowerment
8.1 Resource allocation
8.1.1 # of public meetings held for priority
settings allocation
8.1.2 Procedure for resource allocation is well defined
and commonly known and participation by
stake holders is also well defined and commonly
known
8.2 Strengthening civil society through
enabling
8.2.1 # of active lobbying groups
8.2.2 # of public debates held on public policies

Kausar S Khan. CHS/AKU HEER March 3 2009 13

Overview
Number of Variables & Indicators

S.No Information Numbers

1. Total No. of Bench Marks 9

2. Total No. of Variables 31

3. Total No. of Indicators 139

Kausar S Khan. CHS/AKU HEER March 3 2009 14

Requirements of a Fair System.
Equity, Efficiency, Governance

Equity

Efficiency

Governance

Kausar S Khan. CHS/AKU HEER March 3 2009 15

Using the Benchmarks
What We Need to Know

1. We need to be clear about the design of

our health care system.

2.We must identify what factors contribute

to inequity and unfairness in our system

Kausar S Khan. CHS/AKU HEER March 3 2009 16

Ethical Principle of
Fairness for Health Care
Disease and disability impair the range of
opportunities open to individuals, and that
a principle governing equality of
opportunity provides a basis for regulating
a health care system.
(N. Daniels)

Kausar S Khan. CHS/AKU HEER March 3 2009 17

Fairness

The benchmarks facilitate an integrated

examination of objectives that often
involve trade-offs with each other;
it requires looking across disciplinary
boundaries.
Benchmarks help look for effect of reforms
on the fairness of the resulting system.

Kausar S Khan. CHS/AKU HEER March 3 2009 18

 i d es
d s l
c t e n
Se le r m a
N o
f r o m
ie l ’s n i n
n
Da entat io
e s s h
pr l a d e
a n g
B
0 2
20
Kausar S Khan. CHS/AKU HEER March 3 2009 19
Benchmarks of Fairness:
A policy tool for developing
countries
Norman Daniels
November, 2002

Kausar S Khan. CHS/AKU HEER March 3

2009 20
Some Common Concerns about HS
Trends
 Rising Costs
 Epidemiological Transition
 Privatization and structural reform
 External pressures, transitional economies

 “introduce new resources”

 BUT: undermine public resources

 “avoid state bureaucracy”
 BUT: strong state needed to regulate markets
 Lack of focus on equity, accountability: no integration
 In Grip of Ideology of Market
 Lack of Satisfactory Results

Kausar S Khan. CHS/AKU HEER March 3 2009 21

Key Features of BM

 Country Specific: national, subnational

 Integrates Equity, Efficiency,
Accountability
 Evidence Based (Objectivity)
 Pragmatic
 adapted locally to purposes, evidence
 focus on improvement
 Improves Deliberative Capacity
 Complements other approaches

Kausar S Khan. CHS/AKU HEER March 3 2009 22

Why is evidence base important?
 Evidence base makes evaluation objective
 Making evaluation objective means:
 Explicit interpretation of criteria

 Explicit rules for assessing whether criteria met and

the degree to which alternatives meet them

 Objectivity provides basis for policy deliberation
 Gives points of disagreement a focus that requires

reasons and evidence

Kausar S Khan. CHS/AKU HEER March 3 2009 23

Process of selecting indicators
 Clarity about purpose
 Type of criterion determines type of indicator
 Outcomes vs process indicator appropriate

 Standard vs invented for purpose

 Requires clarity about mechanisms of reform

 Availability of information
 Consultation with experts
 Final selection in light of tentative scoring rules
 Further revision in light of field testing

Kausar S Khan. CHS/AKU HEER March 3 2009 24

Review of Process for Evidence Base
 Refine criteria for particular use, conditions
 Select indicators for criteria
 Initial review of possibilities

 Narrow list to best possibilities -- in consultation with

experts
 Identify source of info, method of gathering

 Develop scoring rules

 For each indicator or set of indicators relevant to

criterion
 May lead to revisions in indicator list

 Field test operationalized benchmarks and revise

Kausar S Khan. CHS/AKU HEER March 3 2009 25

What about disagreements?
 Won’t different groups using bm’s come up with
different scoring rules, different results?
 Yes, but specification of evidence base provides basis

for deliberation about disagreements

 Won’t different groups using same instrument
have come disagreements about evaluations?
 Yes, but specificity of evidence base provides basis

for resolving dispute?

Kausar S Khan. CHS/AKU HEER March 3 2009 26

Information Plus Process
(Note the key words )
 Many approaches aim to give excellent information
input but leave process of deliberation unaffected
 Benchmarks aim to improve process of deliberation
itself
 Adaptation that includes developing evidence base is

training in what to look for when monitoring and

evaluating and how to derive conclusions about reform
from that
 Improvement can take place at any level -- official

policy makers, institutions doing implementation and

lower level planning, community groups assessing
effects

Kausar S Khan. CHS/AKU HEER March 3 2009 27

 m e
o
S ing
l u d s
n c n t
o e
C mm
C o

Kausar S Khan. CHS/AKU HEER March 3 2009 28

 A population view of justice and health
(N.Danials)
“ Level of health in a
population and the
distribution of health status
in it” .
(Norman Daniels. Just Health. Meeting Needs Fairly. Online Book Review.)

Kausar S Khan. CHS/AKU HEER March 3 2009 29

A population view of justice and health
(N.Danials)
1. Social obligation as the fundamental
question of justice for health.
2. Three focal questions:
a) Is health, and therefore health care, and other
factors that affect health , of special moral
importance ?
b) When are health inequalities unjust ?
c) How can we meet health needs fairy under
resource constraints ?

Kausar S Khan. CHS/AKU HEER March 3 2009 30

 Health care

 Healthcare is public health

services and public health
measures.

Kausar S Khan. CHS/AKU HEER March 3 2009 31

 Towards a theory of justice in health care

“As a society, we distribute important goods –

such as education, housing, jobs, income,
wealth, opportunity, political participation, and
a sense of community – very unequially
across subgroups that differ by race, ethnicity,
gender, or class. These social and economic
inequalities then produce health inequalities
through complex mechanism that we are just
beginning to understand.” (N. Daniels. Just Health.
Online Book Review. Page 13)

Kausar S Khan. CHS/AKU HEER March 3 2009 32

What’s the realistic conclusion ?

Some feel
that
problems
exist only
when we
dare to
enter a trap
like this

Kausar S Khan. CHS/AKU HEER March 3 2009 33