This session examines new evaluation techniques to improve our understanding of how well health interventions accomplish their objectives.

1. Assessing the Health Systems Performance of Mexican States Using Effective Coverage Professor Rafael Lozano Innovations in Health Service Evaluation Techniques 18th Annual Global Health Education Consortium Conference April 3 - 5, 2009

3. Sources: INEGI, CONAPO, DGIS, States 32 Municipalities 2,454 Localities 199,230 Population Millions 107.5 Males 52.8 Females 54.7 % Med Insured pop 73.0 % Non Insured pop 27.0 % Urban 78.5 % Rural 21.5 2009 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.2 0.4 0.6 0.8 1.0 1.2 100 90 80 70 60 50 40 30 20 10 0 Millions Male Female 18.2 millions 1st. - 3rd. generation 11.1 millions Born in Mexico 0.8 4.5 5.0 10.0 15.0 20.0 25.0 30.0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2006 Millions Mexican Origin Born in Mexico Migrants to USA

7. Background Objectives Functions Responsiveness Health Fear Financial contribution Stewardship Generation Resource Delivering Services Financing Effective Coverage

8. Effective coverage is the synthesis of three analytical approaches in the study of “coverage” of health services Sociological Studies about access to health services, utilization, identification of barriers, etc. Economics Studies about health care demand concerning prices, quality, distance, etc . Public health Studies of the proportion of the population that receives an intervention (coverage)

12. Establish standardized definitions of need, use and quality for each selected intervention

13. Establish standardized definitions of need, use and quality for each selected intervention Intervention Population in Need Utilization Quality Breast Cancer Screening women aged 40-69 having a mammography within the past year not available Cervical Cancer Screening women aged 25-64 having a pap test within the past year not available Treatment of Vision Disorders adults older than 20 years of age who report near or far visual impairment or wear glasses/contacts use glasses or contacts report no near or far visual impairment when wearing glasses or contacts Glycemic Control in Diabetics fasting plasma glucose or FPG estimated from casual plasma glucose higher than or equal to 126 mg/dl self-reported use of oral hypoglycemics or insulin reduction in fasting plasma glucose compared to treatment targets Treatment of Hypertension adults older than 20 years of age with systolic blood pressure equal or greater than 140mmHg self-reported use of anti-hypertensives reduction in SBP compared to treatment targets Treatment of High Cholesterol adults older than 20 years of age with total cholesterol equal to or greater than 200mg/dl self-reported medication for cholesterol reduction in total cholesterol compared to treatment targets

17. Coverage of Skilled birth attendant for Mexican states, 2005 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Chis Oax Gro Tamp Yuc Ver Qroo Tab Camp Mor BC Col EUM Mex Slp Pue Sin Chih Nay Qro Hgo Dgo Son Zac Tlax Mich Coah NL Ags Jal Gto Bcs DF

18. Coverage of Antenatal Care for Mexican states, 2005

19. Coverage of antenatal care and Skill Birth Attendance by wellbeing quintiles, México 2005 0% 20% 40% 60% 80% 100% 1 2 3 4 5 Coverage Antenatal Care 0% 20% 40% 60% 80% 100% 1 2 3 4 5 Coverage Skill Birth Attendant Households wealth quintiles Low High Low High Source: ENSANUT 2005

20. Crude and effective coverage of treatment for hypertension in Mexican states 2005

21. Prevalence and Effective coverage of treatment for hypertension in Mexican states 2005 Prevalence of population 20years+ Effect. Coverage (HTA controlled) 30-36% 26.4-29.9% 24-26.3% 21.3-23.9% National Prevalence 20.5% (20 years+) 16 millions

22. Hypertension Under Control, 2000-2005 2000 2005 0% 5% 10% 15% 20% No Med Insured SP insured Private Social Security Probability of Being Treated on Antihypertensive Medication by Insurance Type

23. Coverage for cervical and Breast cancer screening in Mexico by household wealth, 2005 Households wealth quintiles Cervical Cancer Screening Breast Cancer Screening 0% 10% 20% 30% 40% 50% 60% 1 2 3 4 5 2000 2005 0% 5% 10% 15% 20% 25% 30% 35% 1 2 3 4 5 2000 2005

24. Composite Index of Effective Coverage

25. Composite effective coverage (14 interventions), maternal and child health intervention coverage (8 interventions) and other adult interventions coverage (6 interventions) by household wealth quintile, Mexico 2005

26. Composite effective coverage (14 interventions) for 2005by state, versus the log of public health expenditure per capita.

27. Change in effective coverage for 8 interventions measured in 2000 that are strictly comparable to 8 interventions* measured in 2005, by state, compared to the percent increase 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.